Automatic quantitative vessel analysis at the location of an automatically-detected tool

ABSTRACT

Apparatus and methods are described including inserting a tool into a blood vessel, and, while the tool is within the blood vessel, acquiring an extraluminal image of the blood vessel. In the extraluminal image of the blood vessel, a location of a portion of the tool with respect to the blood vessel is detected automatically. In response to detecting the location of the portion of the tool, a target portion of the blood vessel that is in a vicinity of the portion of the tool is designated automatically. Using the extraluminal image, quantitative vessel analysis is performed on the target portion of the blood vessel. Other embodiments are also described.

CROSS REFERENCES TO RELATED APPLICATIONS

The present application is a continuation of U.S. application Ser. No.12/666,879 to Steinberg, filed Dec. 28, 2009, which is the US nationalphase of PCT Application no. PCT/IL2009/001089 to Cohen, filed Nov. 18,2009, which claims priority from the following patent applications:

-   -   U.S. Provisional Patent Application 61/193,329, entitled        “Apparatuses and methods for the automatic generation of a road        map from angiographic images of a cyclically-moving organ,” to        Steinberg, filed Nov. 18, 2008    -   U.S. Provisional Patent Application 61/193,915, entitled “Image        processing and tool actuation for medical procedures,” to        Steinberg, filed Jan. 8, 2009    -   U.S. Provisional Patent Application 61/202,181, entitled “Image        processing and tool actuation for medical procedures,” to        Steinberg, filed Feb. 4, 2009    -   U.S. Provisional Patent Application 61/202,451, entitled “Image        processing and tool actuation for medical procedures,” to        Steinberg, filed Mar. 2, 2009    -   U.S. Provisional Patent Application 61/213,216, entitled “Image        processing and tool actuation for medical procedures,” to        Steinberg, filed May 18, 2009    -   U.S. Provisional Patent Application 61/213,534, entitled “Image        Processing and Tool Actuation for Medical Procedures,” to        Steinberg, filed Jun. 17, 2009    -   U.S. Provisional Patent Application 61/272,210, entitled “Image        processing and tool actuation for medical procedures,” to        Steinberg, filed Sep. 1, 2009 and    -   U.S. Provisional Patent Application 61/272,356, entitled “Image        Processing and Tool Actuation for Medical Procedures” to        Steinberg, filed Sep. 16, 2009.

The present application is related to the following patent applications:

-   -   PCT Application PCT/IL2008/000316 to Iddan, filed on Mar. 9,        2008, entitled “Imaging and tools for use with moving organs”    -   U.S. patent application Ser. No. 12/075,244 to Tolkowsky, filed        Mar. 10, 2008, entitled “Imaging for use with moving organs”    -   U.S. patent application Ser. No. 12/075,214 to Iddan, filed Mar.        10, 2008, entitled “Tools for use with moving organs” and    -   U.S. patent application Ser. No. 12/075,252 to Iddan, filed Mar.        10, 2008, entitled “Imaging and tools for use with moving        organs,”

all of which claim the benefit of U.S. Provisional Patent ApplicationNos.:

60/906,091 filed on Mar. 8, 2007,

60/924,609 filed on May 22, 2007,

60/929,165 filed on Jun. 15, 2007,

60/935,914 filed on Sep. 6, 2007, and

60/996,746 filed on Dec. 4, 2007,

all entitled “Apparatuses and methods for performing medical procedureson cyclically-moving body organs.”

The present application is related to the following patent applications:

-   -   PCT Application PCT/IL2009/00610 to Iddan, filed on Jun. 18,        2009, entitled “Stepwise advancement of a medical tool” and    -   U.S. patent application Ser. No. 12/487,315 to Iddan, filed Jun.        18, 2009, entitled “Stepwise advancement of a medical tool,”

both of which claim the benefit of U.S. Provisional Patent ApplicationNo. 61/129,331 to Iddan, filed on Jun. 19, 2008, entitled “Stepwiseadvancement of a medical tool.”

All of the above-mentioned applications are incorporated herein byreference.

FIELD OF EMBODIMENTS OF THE INVENTION

Applications of the present invention generally relate to medicalimaging. Specifically, applications of the present invention relate toimage processing and tool actuation during medical procedures.

BACKGROUND

In the process of angiography, a contrast agent is typicallyadministered to designated vasculature, and is then imaged by means of amedical imaging modality (such as fluoroscopy). The resultingangiographic images are also known as angiograms. Such angiograms maythen be used for constructing a road map of the vasculature, and/or forperforming measurements.

WO 08/107,905 to Iddan describes apparatus for use with a portion of asubject's body that moves as a result of cyclic activity of a bodysystem. An imaging device acquires a plurality of image frames of theportion. A sensor senses a phase of the cyclic activity. A medical toolperforms a function with respect to the portion. A control unitgenerates a stabilized set of image frames of the medical tool disposedwithin the portion, actuates the tool to perform the function or move,in response to the sensor sensing that the cyclic activity is at a givenphase thereof, and inhibits the tool from performing the action ormoving in response to the sensor sensing that the cyclic activity is notat the given phase. A display facilitates use of the tool by displayingthe stabilized set of image frames.

An article by Turski, entitled “Digital Subtraction Angiography ‘RoadMap’” (American Journal of Roentgenology, 1982) describes a techniquecalled roadmapping.

U.S. Pat. No. 4,878,115 to Elion describes a method in which a dynamiccoronary roadmap of the coronary artery system is produced by recordingand storing a visual image of the heart creating a mask sequence,recording and storing another dynamic visual image of the heart afterinjection of a contrast medium thereby creating a contrast sequence,matching the different durations of two sequences and subtracting thecontrast sequence from the mask sequence producing a roadmap sequence.The roadmap sequence is then replayed and added to live fluoroscopicimages of the beating heart. Replay of the roadmap sequence is triggeredby receipt of an ECG R-wave. The result is described as a dynamicallymoving coronary roadmap image which moves in precise synchronizationwith the live incoming fluoroscopic image of the beating heart.

U.S. Pat. No. 4,709,385 to Pfeiler describes an x-ray diagnosticsinstallation for subtraction angiography, which has an image memoryconnected to an output of an x-ray image intensifier video chain whichhas a number of addresses for storing individual x-ray video signalsobtained during a dynamic body cycle of a patient under observation. Adifferencing unit receives stored signals from the image memory as wellas current video signals and subtracts those signals to form asuperimposed image. Entry and readout of signals to and from the imagememory is under the command of a control unit which is connected to thepatient through, for example, an EKG circuit for identifying selectedoccurrences in the body cycle under observation. Entry and readout ofdata from the image memory is described as thereby being controlled insynchronization with the selected occurrences in the cycle.

U.S. Pat. Nos. 5,054,045, 5,457,728, 5,586,201 and 5,822,391 to Whitinggenerally describe a method of displaying details of a coronary arterylesion in a cineangiogram, by digitally adjusting each frame of thecineangiogram so that the lesion is continually displayed at a fixedlocation on a display screen. The remaining cardiac anatomy is describedas appearing to move, in background, past a stationary arterial segment,thus making the displayed arterial segment easier to identify and toexamine by medical personnel. Cineangiographic image frames aredigitized and processed by an image processor and the image frames aredigitally shifted to place the arterial segment in substantially thesame viewing location in each frame. Sequential image frames may bepresented to the viewer as a stereoscopic pair, to producepseudostereopsis. The arterial segment is described as appearing to theviewer in foreground, as if it was floating in front of the remainingcardiac anatomy. Image frames may be further processed to aidexamination by medical personnel. Frames are described as being averagedto reduce quantum noise and to blur any structure noise. Frame averagingis described as being used to make numerical measurements of arterialcross-section.

U.S. Pat. No. 5,293,574 to Roehm describes an x-ray fluorographic systemwhich produces a cineangiogram and enables a feature in the image to beidentified with a cursor and automatically tracked in subsequent images.The identified feature, such as a suspected lesion in a coronary artery,is located in each x-ray frame of the cineangiogram and the data isdescribed as being displayed such that the feature remains motionless inthe center of each successive image.

U.S. Pat. No. 5,809,105 to Roehm describes an x-ray fluorographic systemwhich produces frame images at a low dose rate for both on-line andoff-line use. Background noise is filtered by first producing a maskwhich defines the boundaries of the structural features of interest. Themask is used to select the background pixels for filtering, whileenabling the structural pixels to pass unfiltered to the display.

U.S. Pat. No. 6,088,488 to Hardy describes a reference image R that isselected and a region of interest (ROI) that is interactively selectedencompassing a desired structure from a sequence of images of a movingstructure. This ROI is cross-correlated with other real-time images bymultiplication in the Fourier frequency domain, to determine if thedesired structure is present in the image. If the structure is present,this image may be averaged with other images in which the structure ispresent to produce higher resolution adaptively averaged images. Thetechnique is described as being particularly useful in imaging coronaryvessels. An alternative embodiment is described according to which theoffset of the desired structure is calculated in a series of images. Theimages are then described as being sorted by this offset, and playedback in that order to provide a “movie-like” display of the desiredstructure moving with the periodic motion.

U.S. Pat. No. 6,195,445 to Dubuisson-Jolly describes a technique ofdisplaying a segment of a coronary artery in a stabilized cineangiogram.A computer system receives a sequence of images of a conventionalcineangiogram. A user displays a first image on a monitor and selects apoint on an arterial segment. The computer system invokes an imagetracking procedure that employs active optimal polyline contours tolocate the arterial segment and a fixed point in each of the imageframes of the conventional cineangiogram. The computer system produces astabilized cineangiogram by translating the images to place the arterialsegment in substantially the same viewing location in each one of theimage frames.

U.S. Pat. No. 6,788,827 to Makram-Ebeid describes an image processingmethod for processing the images of an image sequence comprising stepsof determining image data related to first points of an Object ofInterest observed in a first image, said Object of Interest havingpossible movements, and image data related to correlated points found ina second image of the sequence, and based on said image data, ofestimating parameters of sets of transformation functions, whichtransformation functions transform said first points into saidcorrelated points and, from said parameters, of determining one WarpingLaw that automatically transforms said given Object of Interest of thefirst image into the same object in the second image of the sequence forfollowing and locating said Object of Interest in said second image ofthe sequence. The method is described as being applicable to medicalimaging, and X-ray examination apparatus.

U.S. Pat. No. 7,289,652 to Florent describes a medical viewing systemfor displaying a sequence of images of a medical intervention thatcomprises moving and/or positioning a tool in a body organ, which toolis carried by a support to which at least one marker is attached at apredetermined location with respect to the tool, comprising means foracquiring the sequence of images, and for processing said images duringthe medical intervention, wherein: extracting means for automaticallyextracting at least one marker that is attached to the tool support andthat neither belongs to the tool nor to the body organ, and yielding themarker location information; computing means for automatically derivingthe tool location information from the marker location information, andenhancing means for improving the visibility of the tool and/or the bodyorgan in order to check whether the medical intervention stages aresuccessfully carried out.

An article by Frangi, entitled “Multiscale vessel enhancement filtering”(Medical Image Computing and Computer Assisted Intervention—MICCAI1998—Lecture Notes in Computer Science, vol. 1496, Springer Verlag,Berlin, Germany, pp. 130-137) describes the examination of a multiscalesecond order local structure of an image (Hessian), with the purpose ofdeveloping a vessel enhancement filter. A vesselness measure is obtainedon the basis of all eigenvalues of the Hessian. This measure is testedon two dimensional DSA and three dimensional aortoiliac and cerebral MRAdata. Its clinical utility is shown by the simultaneous noise andbackground suppression and vessel enhancement in maximum intensityprojections and volumetric displays.

An article by Dijkstra, entitled “A Note on Two Problems in Connexionwith Graphs” (Numerische Mathematik 1, 269-271, 1959), describes theconsideration of n points (nodes), some or all pairs of which areconnected by a branch, wherein the length of each branch is given. Thediscussion is restricted to the case where at least one path existsbetween any two nodes. A first problem considered is the construction ofa tree of minimum total length between the n nodes. A second problemconsidered is finding the path of minimum total length between two givennodes.

An article by Timinger, entitled “Motion compensated coronaryinterventional navigation by means of diaphragm tracking and elasticmotion models” (Phys Med Biol. 2005 Feb. 7;50(3):491-503) presents amethod for compensating the location of an interventional devicemeasured by a magnetic tracking system for organ motion and thusregistering it dynamically to a 3D virtual roadmap. The motioncompensation is accomplished by using an elastic motion model which isdriven by the ECG signal and a respiratory sensor signal derived fromultrasonic diaphragm tracking

An article by Timinger, entitled “Motion compensation for interventionalnavigation on 3D static roadmaps based on an affine model and gating”(Phys Med Biol. 2004 Mar. 7;49(5):719-32), describes a method forenabling cardiac interventional navigation on motion-compensated 3Dstatic roadmaps.

An article by Zarkh, entitled “Guide wire navigation and therapeuticdevice localization for catheterization procedure” (InternationalCongress Series 1281 (2005) 311-316), describes research into thedevelopment of a system for precise real-time localization of a guidewire tip and therapeutic device, in order to provide assistance in guidewire navigation and accurate device deployment within the coronaryarteries with minimal contrast material injection. The goal is describedas being achieved by real time monitoring of the guide wire tip andtherapeutic device in a sequence of fluoroscopic images, and automaticregistration to the 3D model of the artery.

WO 08/007350 to Sazbon describes a tool for real-time registrationbetween a tubular organ and a device, and a method that utilizes theproposed tool for presenting the device within a reference model of thetubular organ. The proposed tool or markers attached thereto, and thedevice are shown by one imaging modality and the tubular organ is shownby a different imaging modality, but no imaging modality shows both. Dueto the usage of the proposed tool, the registration between the deviceand the tubular organ is significantly simplified and is described asthus, increasing both speed and accuracy.

At the Transvascular Cardiovascular Therapeutics (TCT) conference heldin Washington D.C., USA in October 2008, Paieon Inc. demonstrated theCardiOp-THV system for real-time navigation and positioning of atrans-catheter heart valve.

At the TCT conference held in San Francisco, USA in September 2009,Paieon Inc. demonstrated the IC-PRO Comprehensive Imaging Workstationfor providing assistance in cardiac catheterization procedures. TheWorkstation was described as providing the following functionalities: 3Dreconstruction and analysis and left ventricle analysis; Virtualplanning of single-stent, multiple-stent, or bifurcation procedures;Device visualization during positioning of single or multiple stentingand post-deployment inflation; Device enhancement, post-deploymentanalysis and fusion of stent- and vessel images; and PACS/CVISconnectivity.

Direct Flow Medical Inc. (Santa Rosa, Calif., USA) manufactures theDirect Flow valve.

The following references may be of interest:

U.S. Pat. No. 3,871,360 to Van Horn, U.S. Pat. No. 3,954,098 to Dick,U.S. Pat. No. 4,016,871 to Schiff, U.S. Pat. No. 4,031,884 to Henzel,U.S. Pat. No. 4,245,647 to Randall, U.S. Pat. No. 4,270,143 to Morris,U.S. Pat. No. 4,316,218 to Gay, U.S. Pat. No. 4,382,184 to Wernikoff,U.S. Pat. No. 4,545,390 to Leary, U.S. Pat. No. 4,723,938 to Goodin,U.S. Pat. No. 4,758,223 to Rydell, U.S. Pat. No. 4,849,906 to Chodos,U.S. Pat. No. 4,865,043 to Shimoni, U.S. Pat. No. 4,920,413 to Nakamura,U.S. Pat. No. 4,991,589 to Hongo, U.S. Pat. No. 4,994,965 to Crawford,U.S. Pat. No. 5,020,516 to Biondi, U.S. Pat. No. 5,062,056 to Lo, U.S.Pat. No. 5,176,619 to Segalowitz, U.S. Pat. No. 5,295,486 toWollschlager, U.S. Pat. No. 5,486,192 to Walinsky, U.S. Pat. No.5,538,494 to Matsuda, U.S. Pat. No. 5,619,995 to Lobodzinski, U.S. Pat.No. 5,630,414 to Horbaschek, U.S. Pat. No. 5,764,723 to Weinberger, U.S.Pat. No. 5,766,208 to McEwan, U.S. Pat. No. 5,830,222 to Makower, U.S.Pat. No. 5,971,976 to Wang, U.S. Pat. No. 6,126,608 to Kemme, U.S. Pat.No. 6,233,478 to Liu, U.S. Pat. No. 6,246,898 to Vesely, U.S. Pat. No.6,331,181 to Tierney, U.S. Pat. No. 6,377,011 to Ben-Ur, U.S. Pat. No.6,442,415 to Bis, U.S. Pat. No. 6,473,635 to Rasche, U.S. Pat. No.6,496,716 to Langer, U.S. Pat. No. 6,532,380 to Close, U.S. Pat. No.6,666,863 to Wentzel, U.S. Pat. No. 6,704,593 to Stainsby, U.S. Pat. No.6,708,052 to Mao, U.S. Pat. No. 6,711,436 to Duhaylongsod, U.S. Pat. No.6,728,566 to Subramanyan, U.S. Pat. No. 6,731,973 to Voith, U.S. Pat.No. 6,786,896 to Madhani, U.S. Pat. No. 6,858,003 to Evans, U.S. Pat.No. 6,937,696 to Mostafavi, U.S. Pat. No. 6,959,266 to Mostafavi, U.S.Pat. No. 6,973,202 to Mostafavi, U.S. Pat. No. 6,980,675 to Evron, U.S.Pat. No. 6,999,852 to Green, U.S. Pat. No. 7,085,342 to Younis, U.S.Pat. No. 7,155,046 to Aben, U.S. Pat. No. 7,155,315 to Niemeyer, U.S.Pat. No. 7,180,976 to Wink, U.S. Pat. No. 7,191,100 to Mostafavi, U.S.Pat. No. 7,209,779 to Kaufman, U.S. Pat. No. 7,269,457 to Shafer, U.S.Pat. No. 7,321,677 to Evron, U.S. Pat. No. 7,339,585 to Verstraelen,U.S. Pat. No. 7,587,074 to Zarkh;

US 2002/0049375 to Strommer, US 2002/0188307 to Pintor, US 2003/0018251to Solomon, US 2003/0023141 to Stelzer, US 2003/0157073 to Peritt, US2004/0077941 to Reddy, US 2004/0097805 to Verard, US 2004/0176681 toMao, US 2005/0008210 to Evron, US 2005/0054916 to Mostafavi, US2005/0090737 to Burrel, US 2005/0107688 to Strommer, US 2005/0137661 toSra, US 2005/0143777 to Sra, US 2006/0074285 to Zarkh, US 2006/0287595to Maschke, US 2006/0058647 to Strommer, US 2007/0053558 to Puts, US2007/0106146 to Altmann, US 2007/0142907 to Moaddeb, US 2007/0173861 toStrommer, US 2007/0208388 to Jahns, US 2007/0219630 to Chu;

WO 94/010904 to Nardella, WO 01/43642 to Heuscher, WO 03/096894 to Ho,WO 05/026891 to Mostafavi, WO 05/124689 to Manzke, WO 06/066122 to Sra,WO 06/066124 to Sra;

“3D imaging in the studio and elsewhere,” by Iddan (SPIE ProceedingsVol. 4298, 2001);

“4D smoothing of gated SPECT images using a left-ventricle shape modeland a deformable mesh,” by Brankov, (Nuclear Science SymposiumConference Record, 2004 IEEE, October 2004, Volume: 5, 2845-2848);

“4D-CT imaging of a volume influenced by respiratory motion onmulti-slice CT Tinsu Pan,” by Lee, (Medical Physics, February 2004,Volume 31, Issue 2, pp. 333-340);

“Assessment of a Novel Angiographic Image Stabilization System forPercutaneous Coronary Intervention” by Boyle (Journal of InterventionalCardiology,” Vol. 20 No. 2, 2007);

“Cardiac Imaging: We Got the Beat!” by Elizabeth Morgan (MedicalImaging, March 2005);

“Catheter Insertion Simulation with Combined Visual and HapticFeedback,” by Zorcolo (Center for Advanced Studies, Research andDevelopment in Sardinia);

“Full-scale clinical implementation of a video based respiratory gatingsystem,” by Ramsey, (Engineering in Medicine and Biology Society, 2000.Proceedings of the 22nd Annual International Conference of the IEEE,2000, Volume: 3, 2141-2144);

“New 4-D imaging for real-time intraoperative MRI: adaptive 4-D scan,”by Tokuda (Med Image Comput Assist Intery Int Conf. 2006;9(Pt1):454-61);

“Noninvasive Coronary Angiography by Retrospectively ECG-GatedMultislice Spiral CT,” by Achenbach, (Circulation. 2000 Dec.5;102(23):2823-8);

“Prospective motion correction of X-ray images for coronaryinterventions,” by Shechter (IEEE Trans Med Imaging. 2005 April;24(4):441-50);

“Real-time interactive viewing of 4D kinematic MR joint studies,” bySchulz (Med Image Comput Assist Intery Int Conf. 2005;8(Pt 1):467-73.);

“Spatially-adaptive temporal smoothing for reconstruction of dynamic andgated image sequences,” by Brankov, (Nuclear Science SymposiumConference Record, 2000 IEEE, 2000, Volume: 2, 15/146-15/150);

“Three-Dimensional Respiratory-Gated MR Angiography of the CoronaryArteries: Comparison with Conventional Coronary Angiography,” by Post,(AJR, 1996; 166: 1399-1404).

SUMMARY OF EMBODIMENTS

For some applications of the present invention, apparatus and methodsare provided for use in image processing and tool actuation in thecourse of a coronary angioplasty procedure. For example, apparatus andmethods are provided for: automated generation of a road-map, thegeneration of automated measurements, automatic image stabilization,automatic image enhancement, tool positioning and tool deployment.

For some applications, a road map is displayed together with astabilized image stream.

Typically, image processing as described in the present application isperformed on-line. However, the scope of the present applicationincludes performing the techniques described herein off line.

Although many of the applications of the present invention are describedwith reference to the diagnosis and treatment of the coronary arteriesin the context of coronary angiography and/or angioplasty, the scope ofthe present invention includes applying the apparatus and methodsdescribed herein to other medical procedures. The scope of the presentinvention includes applying the techniques described herein to anybodily lumen or cavity on which diagnosis and/or treatment may beperformed, including but not limited to the vascular system, chambers ofthe heart, the bronchial tract, the gastro-intestinal tract, or anycombination thereof, and using any form of imaging and any applicablemedical tool. For example, the scope of the present invention includesapplying the apparatus and methods described herein to valve replacementor repair, closure of septal defects, ablation of cardiac tissue, orother medical interventions, as described in further detail hereinbelow.

For some applications, one or more of the procedures described herein isperformed under guidance of an image stream that has been image trackedwith respect to a portion of a tool that is used for the procedure.Typically, performing the procedure using such image guidancefacilitates the performance of the procedure by a healthcareprofessional.

For some applications, a medical tool is actuated in synchronizationwith the cyclical motion of the organ being imaged. For someapplications, in addition to the medical tool being actuated insynchronization with the cyclical motion of an organ, a stabilized imagestream of the organ is displayed.

For some applications, the techniques described herein are performed incombination with techniques described in PCT ApplicationPCT/IL2008/000316 to Iddan (published as WO 08/107905), filed on Mar. 9,2008, entitled “Imaging and tools for use with moving organs,” which isincorporated herein by reference.

For some applications, the techniques described herein are performed incombination with techniques described in PCT ApplicationPCT/IL2009/00610 to Iddan, filed on Jun. 18, 2009, entitled “Stepwiseadvancement of a medical tool,” which is incorporated herein byreference.

There is therefore provided, in accordance with some applications of thepresent invention, a method, including:

receiving into at least one processor a set of images of blood vesselsof a subject;

generating a road map of the subject's blood vessels, by automatically:

-   -   deriving at least one image from the set of images of the blood        vessels, based upon visibility of at least a portion of the        blood vessels in the set of images; and    -   in the derived image, determining a location of edge lines of at        least some of the portion of the blood vessels in the image; and

generating an output by the processor, based on the road map.

For some applications, generating the output includes overlaying theedge lines on an image stream that is based upon the set of images.

For some applications, generating the output includes overlaying theedge lines on a single image that is derived from the set of images.

For some applications, generating the road map includes generating aroad map that corresponds to a given phase of a motion cycle of theblood vessels, and generating the output includes overlaying the roadmap on an image stream of the blood vessels that is gated to the givenphase.

For some applications, generating the road map includes generating theroad map in real time.

For some applications, generating the road map includes generating theroad map in near real time.

For some applications, the method further includes generating distanceindicators along the edge lines.

For some applications, generating the road map further includesautomatically enhancing the at least some of the portion of the bloodvessels in the derived image.

For some applications, determining the location of the edge linesincludes determining a location of discontinuous edge lines using imageprocessing, and filling gaps in the discontinuous edge lines using agap-filling algorithm.

For some applications, deriving the at least one image from the set ofimages includes selecting a single image from the set of images, basedupon visibility of at least a portion of the blood vessels in the set ofimages.

For some applications, deriving the at least one image from the set ofimages includes selecting two or more images from the set of images,based upon visibility of at least a portion of the blood vessels in theset of images, and generating an image, based upon the two or moreimages.

For some applications, generating the image based upon the two or moreimages includes aggregating the two or more images.

For some applications, generating the road map includes, using imageprocessing, automatically deriving lines that correspond to paths of theat least some of the portion of the blood vessels in the derived image,and determining the location of the edge lines includes determining thelocation of the edge lines based upon the lines that correspond to thepaths.

For some applications, the lines that correspond to the paths arediscontinuous and have end points at discontinuities in the lines, andthe method further includes automatically generating continuous linesthat correspond to the paths, by bridging the discontinuities in thediscontinuous lines.

For some applications, determining the location of the edge linesincludes using a penalty function that is based upon the lines thatcorrespond to the paths.

There is further provided, in accordance with some applications of thepresent invention, apparatus, including:

an image-acquisition device configured to acquire a set of images ofblood vessels of a subject;

a display; and

at least one processor, including:

-   -   image-receiving functionality configured to receive the set of        images into the processor;    -   image-derivation functionality configured to automatically        derive at least one image from the set of images of the blood        vessels, based upon visibility of at least a portion of the        blood vessels in the set of images; and    -   edge-line-determination functionality configured to        automatically generate a road map by determining a location of        edge lines of at least some of the portion of the blood vessels        in the derived image; and    -   display-driving functionality configured to drive the display to        display an output to a user based upon the road map.

For some applications, the processor further includesdistance-indicating functionality configured to generate distanceindicators along the edge lines, and the display-driving functionalityis configured to drive the display to display the distance indicatorsalong the edge lines.

For some applications, the processor further includes image-enhancementfunctionality configured to automatically enhance the at least some ofthe portion of the blood vessels in the derived image.

For some applications, the processor further includes line-derivationfunctionality configured, using image processing, to automaticallyderive lines that correspond to paths of at least the some of theportion of the blood vessels in the image, and theedge-line-determination functionality is configured to determine thelocation of the edge lines based upon the lines that correspond to thepaths.

For some applications, the lines that correspond to the paths arediscontinuous and have end points at discontinuities in the lines, andthe processor further includes line-bridging functionality configuredto, automatically, generate continuous lines that correspond to thepaths of the portion of the blood vessels in the image, by bridging thediscontinuities in the discontinuous lines.

There is additionally provided, in accordance with some applications ofthe present invention, a method, including:

receiving into at least one processor at least one image of bloodvessels of a subject;

using image processing, automatically deriving discontinuous lines thatcorrespond to paths of at least a portion of the blood vessels in theimage, the lines having end points at discontinuities in the lines;

automatically generating continuous lines that correspond to the pathsof the portion of the blood vessels in the image by bridging thediscontinuities in the discontinuous lines; and

generating an output by the processor, based on the continuous lines.

For some applications, receiving the at least one image includesreceiving into the processor a plurality of images of the blood vessels,and generating the output includes overlaying the lines on an imagestream that is based upon the plurality of images.

For some applications, generating the output includes overlaying thelines on the image of the blood vessels.

For some applications, generating the output includes overlaying thelines on a current real time image stream of the blood vessels.

For some applications, generating the lines includes generating linescorresponding to the paths of the blood vessels during a given phase ofa motion cycle of the blood vessels, and generating the output includesoverlaying the lines on an image stream of the blood vessels that isgated to the given phase.

For some applications, generating the continuous lines includesgenerating the continuous lines in real time.

For some applications, generating the continuous lines includesgenerating the continuous lines in near real time.

For some applications, the method further includes automaticallydetermining a location of edge lines of the portion of the bloodvessels, based upon the lines that correspond to the paths.

For some applications, deriving the discontinuous lines includesderiving discontinuous lines that correspond to center lines of theportion of the blood vessels.

For some applications, deriving the discontinuous lines includesderiving lines corresponding to paths of the blood vessels, based uponthe lines having greater visibility than other lines corresponding topaths of the blood vessels in the at least one image.

For some applications, adjacent to at least one first end point of theend points, there are a plurality of second end points of the endpoints, and bridging the discontinuities includes determining to whichof the second end points to bridge from the first end point.

For some applications, receiving the image includes receiving an imagethat was acquired in a presence of a contrast agent.

For some applications, bridging the discontinuities includes bridgingthe discontinuities based upon a shortest-path algorithm.

For some applications, bridging the discontinuities includes bridgingthe discontinuities based upon a known structure of the portion of theblood vessels.

There is further provided, in accordance with some applications of thepresent invention, apparatus, including:

an image-acquisition device configured to acquire at least one image ofblood vessels of a subject;

a display; and

at least one processor, including:

-   -   image-receiving functionality configured to receive the at least        one image into the processor;    -   line-derivation functionality configured, using image        processing, to automatically derive discontinuous lines that        correspond to paths of at least a portion of the blood vessels        in the image, the lines having end points at discontinuities in        the lines;    -   line-bridging functionality configured to, automatically,        generate continuous lines that correspond to the paths of the        portion of the blood vessels in the image, by bridging the        discontinuities in the discontinuous lines; and    -   display-driving functionality configured to drive the display to        display an output to a user based on the continuous lines.

For some applications, the processor further includesedge-line-determination functionality configured to determine a locationof edge lines of the portion of the blood vessels, based upon the linesthat correspond to the paths.

There is additionally provided, in accordance with some applications ofthe present invention, a method for use with blood vessels of a subjectthat move cyclically, in accordance with a motion cycle, including:

receiving into at least one processor a set of images of the bloodvessels;

automatically, deriving at least one image from the set of images of theblood vessels, based upon:

-   -   (a) timing of acquisition of images from the set of images with        respect to the motion cycle, and    -   (b) visibility of at least a portion of the blood vessels in the        set of images; generating a road map based upon the derived        image; and

generating an output based upon the road map.

For some applications, receiving the set of images includes receiving aset of angiographic images.

For some applications, deriving the at least one image from the set ofimages includes selecting a single image from the set of images, basedupon the (a) timing of acquisition of images from the set of images withrespect to the motion cycle, and (b) visibility of at least a portion ofthe blood vessels in the set of images.

For some applications, deriving the at least one image from the set ofimages includes:

selecting two or more images from the set of images, based upon the (a)timing of acquisition of images from the set of images with respect tothe motion cycle, and (b) visibility of at least a portion of the bloodvessels in the set of images; and

generating an image, based upon the two or more images.

For some applications, generating the image based upon the two or moreimages includes aggregating the two or more images.

There is further provided, in accordance with some applications of thepresent invention, apparatus for use with blood vessels of a subjectthat move cyclically, in accordance with a motion cycle, including:

an image-acquisition device configured to acquire a set of images of theblood vessels;

a display; and

at least one processor, including:

-   -   image-receiving functionality configured to receive the set of        images into the processor;    -   image-derivation functionality configured to automatically        derive at least one image from the set of images of the blood        vessels, based upon:        -   (a) timing of acquisition of images from the set of images            with respect to the motion cycle, and        -   (b) visibility of at least a portion of the blood vessels in            the set of images;    -   road-map-generation functionality configured to generate a road        map based upon the derived image; and    -   display-driving functionality configured to drive the display to        display an output to a user based upon the road map.

There is further provided, in accordance with some applications of thepresent invention, a method, including:

generating a road map of a blood vessel;

subsequently, inserting a tool into the blood vessel;

while the tool is inside the blood vessel, determining a position of thetool; and

modifying the road map to account for the determined position of thetool.

For some applications, the tool includes a wire, and inserting the toolinto the blood vessel includes inserting the wire into the blood vessel.

For some applications, the tool includes a catheter, and inserting thetool into the blood vessel includes inserting the catheter into theblood vessel.

There is additionally provided, in accordance with some applications ofthe present invention, apparatus, including:

an image-acquisition device configured to acquire a set of images ofblood vessels of a subject;

a tool configured to be placed inside one of the blood vessels;

a display; and

at least one processor, including:

-   -   image-receiving functionality configured to receive the set of        images into the processor;    -   road-map-generation functionality configured to generate a road        map of the blood vessels, based upon the set of images;    -   tool-location functionality configured to determine a location        of the tool subsequent to the generation of the road map; and    -   road-map-modification functionality configured to modify the        road map to account for the determined position of the tool; and    -   display-driving functionality configured to drive the display to        display an output to a user based on the modified road map.

There is further provided, in accordance with some applications of thepresent invention, a method for use with an image of blood vessels of asubject, including:

in response to a user designating a single point on the image:

-   -   automatically identifying a target portion of a blood vessel in        a vicinity of the designated point;    -   performing quantitative vessel analysis on the target portion of        the blood vessel; and

generating an output based upon the quantitative vessel analysis.

For some applications, the blood vessel includes a coronary artery, andperforming the quantitative vessel analysis with respect to the bloodvessel includes performing quantitative coronary angiography.

For some applications, identifying the target portion includesdesignating a longitudinal portion of the blood vessel having a proximalend that is at a first distance from the point in a proximal direction,and having a distal end that is at a second distance from the point in adistal direction.

For some applications, performing quantitative vessel analysis withrespect to the longitudinal portion includes determining a minimumdiameter of the blood vessel within the longitudinal portion.

For some applications, designating the longitudinal portion includesdesignating a longitudinal portion, the first and second distances ofwhich are equal to each other.

For some applications, designating the longitudinal portion includesdesignating a longitudinal portion, the first and second distances ofwhich are different from each other.

For some applications, designating the longitudinal portion includesdesignating a longitudinal portion, a sum of the first and seconddistances of which corresponds to a length of a given tool.

For some applications, identifying the target portion includesidentifying a portion of the blood vessel that corresponds to a lesion.

For some applications, performing quantitative vessel analysis includesdetermining a minimum diameter of the lesion.

For some applications, performing quantitative vessel analysis includesdetermining a maximum diameter of the lesion.

For some applications, performing quantitative vessel analysis includesdetermining a length of the lesion.

For some applications, identifying the portion of the blood vessel thatcorresponds to the lesion includes identifying edge lines of the bloodvessel.

For some applications, identifying the portion of the blood vessel thatcorresponds to the lesion includes identifying proximal and distallongitudinal locations of the blood vessel at which the lesion ends.

There is further provided, in accordance with some applications of thepresent invention, apparatus, including:

a display configured to display an image of blood vessels of a subject;

an input device; and

at least one processor, including:

-   -   target-identification functionality configured, in response to a        user designating a single point on the image, using the input        device, to automatically identify a target portion of a blood        vessel in a vicinity of the designated point;    -   quantitative-vessel-analysis functionality configured to perform        quantitative vessel analysis on the target portion of the blood        vessel; and    -   display-driving functionality configured to drive the display to        display an output in response to the quantitative vessel        analysis.

There is additionally provided, in accordance with some applications ofthe present invention, a method for use with an image of blood vesselsof a subject, including:

in response to a user designating a single point on the image:

automatically identifying a portion of a blood vessel in a vicinity ofthe designated point that corresponds to a lesion, by:

-   -   automatically determining a location of edge lines of the blood        vessel, and    -   automatically determining longitudinal locations along the blood        vessel that correspond to ends of the lesion; and

generating an output in response to the identification of the portionthat corresponds to the lesion.

For some applications, the method further includes performingquantitative vessel analysis with respect to the portion.

There is further provided, in accordance with some applications of thepresent invention, apparatus, including:

a display configured to display an image of blood vessels of a subject;

an input device; and

at least one processor, including:

-   -   lesion-identification functionality configured, in response to a        user designating a single point on the image, using the input        device, to identify a portion of a blood vessel in a vicinity of        the designated point that corresponds to a lesion, by:        -   automatically determining a location of edge lines of the            blood vessel, and        -   automatically determining longitudinal locations along the            blood vessel that correspond to ends of the lesion; and    -   display-driving functionality configured to drive the display to        display an output in response to the identification of the        portion that corresponds to the lesion.

For some applications, the processor further includesquantitative-vessel-analysis functionality configured to performquantitative vessel analysis on the identified portion.

There is additionally provided, in accordance with some applications ofthe present invention, a method for use with an image of blood vesselsof a subject, including:

in response to a user designating a first longitudinal location of ablood vessel, and subsequently designating a plurality of additionallongitudinal locations of the blood vessel,

automatically determining a parameter of the blood vessel at each of theadditional locations selected from the group consisting of:

-   -   a diameter of the blood vessel associated with the additional        location,    -   a level of occlusion of the blood vessel associated with the        additional location, and    -   a longitudinal distance along the blood vessel associated with        the additional location; and

generating an output in response to the determined parameter at each ofthe locations.

For some applications, determining the selected parameter includesdetermining an average diameter of the blood vessel between the firstlongitudinal location and the additional location.

For some applications, determining the selected parameter includesdetermining a minimum diameter of the blood vessel between the firstlongitudinal location and the additional location.

For some applications, determining the selected parameter includesdetermining a diameter of the blood vessel at the additional location.

For some applications, determining the selected parameter includesdetermining a longitudinal distance from the first longitudinal locationto the additional location.

For some applications, determining the selected parameter includesdetermining a longitudinal distance from an end of a lesion of the bloodvessel to the additional location.

For some applications, determining the parameter includes determining aminimum lumen diameter associated with the additional location.

There is further provided, in accordance with some applications of thepresent invention, apparatus, including:

a display configured to display an image of blood vessels of a subject;

an input device; and

at least one processor, including:

-   -   parameter-determination functionality configured, in response to        a user designating a first longitudinal location of a blood        vessel, and subsequently designating a plurality of additional        longitudinal locations of the blood vessel, to automatically        determine a parameter of the blood vessel at each of the        additional locations, the parameter selected from the group        consisting of:        -   a diameter of the blood vessel associated with the            additional location,        -   a level of occlusion of the blood vessel associated with the            additional location, and        -   a longitudinal distance along the blood vessel associated            with the additional location; and    -   display-driving functionality configured to drive the display to        display an output in response to the determined parameter.

There is additionally provided, in accordance with some applications ofthe present invention, a method for use with an image of blood vesselsof a subject, including:

displaying a cursor in a vicinity of one of the blood vessels on theimage; and

in response to receiving an input from a user indicating that the cursorshould be moved, only allowing movement of the cursor along a directionof paths of the blood vessels.

For some applications, only allowing movement of the cursor along thedirection of the paths includes allowing movement of the cursor withinthe blood vessels along the direction of the paths.

For some applications, only allowing movement of the cursor along thedirection of the paths includes allowing movement of the cursoralongside the blood vessels, along the direction of the paths.

There is further provided, in accordance with some applications of thepresent invention, apparatus, including:

a display;

an input device; and

at least one processor, including:

-   -   display-driving functionality configured to drive the display to        display a cursor in an image of blood vessels of a subject, in a        vicinity of one of the blood vessels on the image; and    -   cursor-control functionality configured (a) in response to        receiving an input from a user, via the input device, indicating        that the cursor should be moved, (b) only to allow movement of        the cursor along a direction of paths of the blood vessels.

There is additionally provided, in accordance with some applications ofthe present invention, a method, including:

generating a sequence of endoluminal cross-sectional images ofrespective sections of a blood vessel of a subject;

generating an extraluminal image of the blood vessel;

determining that respective regions of the extraluminal image of theblood vessel correspond to the sections;

determining dimensions of at least some of the regions of theextraluminal image by performing quantitative vessel analysis withrespect to the at least some of the regions of the extraluminal image;and

displaying at least some of the endoluminal images of respectivesections of the blood vessel together with the dimensions of thecorresponding region.

For some applications, determining that respective regions of theextraluminal image of the blood vessel correspond to the sectionsincludes registering the extraluminal image with the endoluminal images.

There is further provided, in accordance with some applications of thepresent invention, apparatus, including:

an endoluminal imaging device configured to acquire a sequence ofendoluminal cross-sectional images of respective sections of a bloodvessel of a subject;

an extraluminal imaging device configured to acquire at least oneextraluminal image of the blood vessel;

a display; and

at least one processor, including:

-   -   image-receiving functionality configured to receive the        endoluminal and extraluminal images;    -   image-assigning functionality configured to determine that        respective regions of the extraluminal image of the blood vessel        correspond to the sections; and    -   dimension-determining functionality configured to determine        dimensions of at least some of the regions of the extraluminal        image by performing quantitative vessel analysis with respect to        the at least some of the regions of the extraluminal image; and    -   display-driving functionality configured to drive the display to        display at least some of the endoluminal images of respective        sections of the blood vessel together with the dimensions of the        corresponding region.

There is additionally provided, in accordance with some applications ofthe present invention, a method, including:

inserting a tool into a blood vessel;

while the tool is within the blood vessel, acquiring an extraluminalimage of the blood vessel;

in the extraluminal image of the blood vessel, automatically detecting alocation of a portion of the tool with respect to the blood vessel;

in response to detecting the location of the portion of the tool,automatically designating a target portion of the blood vessel that isin a vicinity of the portion of the tool; and

using the extraluminal image, performing quantitative vessel analysis onthe target portion of the blood vessel.

For some applications, the tool includes a balloon, and inserting thetool includes inserting the balloon.

For some applications, the tool includes a replacement valve, andinserting the tool includes inserting the replacement valve.

For some applications, the tool includes a stent, and inserting the toolincludes inserting the stent.

For some applications, the tool includes a graft, and inserting the toolincludes inserting the graft.

There is further provided, in accordance with some applications of thepresent invention, apparatus, including:

a tool configured to be placed inside a blood vessel of a subject;

an extraluminal image-acquisition device configured to acquire an imageof the blood vessel, while the tool is inside the blood vessel;

a display; and

at least one processor, including:

-   -   image-receiving functionality configured to receive the image        into the processor;    -   tool-detection functionality configured to automatically detect        a location of a portion of the tool, with respect to the blood        vessel, in the image;    -   target-designation functionality configured, in response to        detecting the location of the portion of the tool, to        automatically designate a target portion of the blood vessel        that is in a vicinity of the portion of the tool;    -   quantitative-vessel-analysis functionality configured to perform        quantitative vessel analysis on the target portion of the blood        vessel, using the image; and    -   display-driving functionality configured to drive the display to        display an output in response to the quantitative vessel        analysis.

There is additionally provided, in accordance with some applications ofthe present invention, a method for imaging a tool inside a portion of asubject's body that undergoes motion, the method including:

acquiring a plurality of image frames of the portion of the subject'sbody;

image tracking the image frames by:

-   -   automatically identifying at least a feature of the tool in at        least a portion of the image frames, and    -   aligning the tool in image frames of the portion of the image        frames, based on the automatic identifying; and

displaying, as an image stream, the image-tracked image frames of theportion of the subject's body.

For some applications, aligning the tool includes translating at leastone of the image frames.

For some applications, aligning the tool includes rotating at least oneof the image frames.

For some applications, aligning the tool includes scaling at least oneof the image frames.

For some applications, the tool includes a balloon, and automaticallyidentifying at least the feature of the tool includes automaticallyidentifying at least a feature of the balloon.

For some applications, the tool includes a stent, and automaticallyidentifying at least the feature of the tool includes automaticallyidentifying at least a feature of the stent.

For some applications, the tool includes a graft, and automaticallyidentifying at least the feature of the tool includes automaticallyidentifying at least a feature of the graft.

For some applications, the tool includes a replacement valve, andautomatically identifying at least the feature of the tool includesautomatically identifying at least a feature of the replacement valve.

For some applications, the tool includes a hole-closing tool for closinga hole in a septal wall, and automatically identifying at least thefeature of the tool includes automatically identifying at least afeature of the hole-closing tool.

For some applications, the tool includes a valve-placement tool forfacilitating placement of a replacement valve, and automaticallyidentifying at least the feature of the tool includes automaticallyidentifying at least a feature of the valve-placement tool.

For some applications,

the tool includes a tool selected from the group consisting of: acatheter, an energy-application tool, apercutaneous-myocardial-revascularization tool, a substance-deliverytool, a tissue-repair tool, a trans-thoracic-needle, and atrans-bronchial needle, and

automatically identifying at least the feature of the tool includesautomatically identifying at least a feature of the selected tool.

For some applications, the tool includes a valve-repair tool, andautomatically identifying at least the feature of the tool includesautomatically identifying at least a feature of the valve-repair tool.

For some applications, the tool includes a valve-suturing tool forsuturing a valve, and automatically identifying at least the feature ofthe tool includes automatically identifying at least a feature of thevalve-suturing tool.

For some applications, the tool includes a valve-leaflet-clipping toolfor clipping a valve, and automatically identifying at least the featureof the tool includes automatically identifying at least a feature of thevalve-leaflet-clipping tool.

For some applications, displaying the image-tracked image framesincludes displaying an image stream in which motion of the tool relativeto the portion of the subject's body is visible, but motion of the toolthat is the same as motion of the portion of the subject's body is notvisible.

For some applications, displaying the image-tracked image framesincludes displaying an image stream in which motion of the tool relativeto the portion of the subject's body over a cycle of cyclical motion ofthe portion of the subject's body is shown.

For some applications, the method further includes designating at leastone image frame as not providing sufficient visibility of the feature ofthe tool, and, in response to designating the image frame, notdisplaying the designated image frame in the image stream.

For some applications, the method further includes blending into eachother a frame that was acquired immediately before acquisition of thedesignated image frame, and a frame that was acquired immediately afterthe acquisition of the designated image frame.

For some applications, identifying the feature of the tool includesderiving a feature of the tool from at least one portion of the toolthat is generally visible in the image frames.

For some applications, deriving the feature includes deriving a virtualline that connects radiopaque portions of the tool.

For some applications, deriving the feature includes deriving an averagelocation of radiopaque portions of the tool.

For some applications, identifying the feature of the tool includesidentifying at least one radiopaque marker of the tool.

For some applications, identifying the marker includes distinguishingbetween the marker and contrast agent.

For some applications, identifying the marker includes distinguishingbetween the marker and overlap of a set of two portions of an imageframe of the portion of the image frames, the set being selected fromthe group consisting of two blood vessels, two tool portions, a bloodvessel and a tool portion, a blood vessel and a rib, and a tool portionand a rib.

For some applications, identifying the marker includes identifying themarker by accounting for blurring of the marker in a dynamic imagestream that is based on the plurality of image frames.

There is further provided, in accordance with some applications of thepresent invention, apparatus for use with a portion of a subject's bodythat undergoes motion, the apparatus including:

a tool configured to be placed inside the portion;

an image-acquisition device configured to acquire a plurality of imageframes of the portion of the subject's body;

a display; and

at least one processor configured to image track the image frames, theprocessor including:

-   -   image-receiving functionality configured to receive the image        frames into the processor;    -   tool-identifying functionality configured to automatically        identify at least a feature of the tool in at least a portion of        the image frames; and    -   frame-aligning functionality configured to align the tool in        image frames of the portion of the image frames, based on the        automatic identifying; and    -   display-driving functionality configured to drive the display to        display, as an image stream, the image-tracked image frames of        the portion of the subject's body.

There is further provided, in accordance with some applications of thepresent invention, apparatus including:

a sensor for sensing a phase of the cyclic activity;

a tool configured to be deployed within a blood vessel of a subject;

a balloon having a central portion disposed inside the tool andoverhanging portions that are disposed outside the tool, the balloonconfigured to couple the tool to the blood vessel, by the balloon beinginflated inside the tool while the balloon and the tool are inside theblood vessel; and

a control unit configured, while the balloon and the tool are inside theblood vessel, to inflate the balloon such that at least one of theoverhanging portions of the balloon becomes appositioned to an innersurface of the blood vessel, in response to the sensor sensing that thecyclic activity is at a given phase thereof.

For some applications, the control unit is configured to inflate theballoon continuously during at least one period selected from the groupconsisting of: a period before the balloon becomes appositioned to thesurface, and a period after the balloon becomes appositioned to thesurface.

For some applications, the tool includes a tool selected from the groupconsisting of a stent, a replacement valve, and a graft.

There is additionally provided, in accordance with some applications ofthe present invention, a method for imaging a portion of a body of asubject that undergoes motion, the method including:

acquiring a plurality of image frames of the portion of the subject'sbody; and

generating a stream of image frames in which a vicinity of a givenfeature of the image frames is enhanced, by:

-   -   automatically identifying the given feature in each of the image        frames,    -   aligning the given feature in two or more image frames of the        plurality of image frames,    -   averaging sets of two or more of the aligned frames to generate        a plurality of averaged image frames, and    -   displaying as a stream of image frames the plurality of averaged        image frames.

For some applications,

acquiring the plurality of image frames includes acquiring,sequentially, first and second image frames of the portion of thesubject's body, and

generating the stream of image frames in which the vicinity of the givenfeature of the image frames is enhanced includes:

-   -   generating a first moving average image frame using frames of        the portion of the subject's body acquired prior to the        acquisition of the first and second image frames;    -   aligning the given feature in the first image frame with the        given feature in the first moving-average image frame;    -   when the given feature is aligned in the first image frame and        the first moving-average image frame, averaging the first image        frame and the first moving-average image frame to generate a        second moving-average image frame;    -   aligning the given feature in the second moving-average image        frame and the second image frame;    -   when the given feature is aligned in the second moving-average        image frame and the second image frame, averaging the second        image frame with the second moving-average image frame to        generate a third moving-average image frame; and    -   displaying, in an image stream, the first, second, and third        moving-average image frames.

There is further provided, in accordance with some applications of thepresent invention, apparatus for use with a portion of a body of asubject that undergoes motion, the apparatus including:

an image-acquisition device configured to acquire a plurality of imageframes of the portion of the subject's body;

a display; and

at least one processor configured to generate a stream of image framesin which a vicinity of a given feature of the image frames is enhanced,the processor including:

-   -   image-receiving functionality configured to receive the        plurality of image frames into the processor,    -   feature-identifying functionality configured to automatically        identify the given feature in each of the image frames,    -   image-alignment functionality configured to align the given        feature in two or more image frames of the plurality of image        frames, and    -   image-averaging functionality configured to average sets of two        or more of the aligned frames to generate a plurality of        averaged image frames; and    -   display-driving functionality configured to drive the display to        display, as a stream of image frames, the plurality of averaged        image frames.

There is further provided, in accordance with some applications of thepresent invention, a method for actuating a tool to perform a functionon a body of a subject at a given phase of a motion cycle of thesubject's body, the method including:

determining a duration of the motion cycle;

in a first motion cycle of the subject, detecting the given phase of thesubject's motion cycle; and

actuating the tool to perform the function at a given time afterdetecting the given phase of the first motion cycle, the given timebeing determined by subtracting a correction factor from the duration ofthe motion cycle.

For some applications, determining the duration of the cycle includesdetermining an average duration of a plurality of motion cycles of thesubject.

For some applications, determining the duration of the cycle includesdetermining a duration of a single previous motion cycle of the subject.

For some applications, the tool includes a valve-placement tool forfacilitating placement of a replacement valve, and actuating the tool toperform the function includes actuating the tool to facilitate placementof the valve.

For some applications, the tool includes a valve-repair tool forrepairing a valve, and actuating the tool to perform the functionincludes actuating the tool to repair the valve.

For some applications, the tool includes a balloon, and actuating thetool to perform the function includes actuating the balloon to becomeinflated.

For some applications, the tool includes a stent, and actuating the toolto perform the function includes actuating the stent to become deployed.

For some applications, the tool includes a graft, and actuating the toolto perform the function includes actuating the graft to become deployed.

For some applications, the correction factor includes a detection-delaycorrection factor that is associated with a delay between an occurrenceof the given phase and detection of the given phase, and actuating thetool to perform the function includes actuating the tool to perform thefunction at a given time after detecting the given phase of the firstmotion cycle, the given time being determined by subtracting thedetection-delay correction factor from the duration of the motion cycle.

For some applications, the correction factor includes a mechanical-delaycorrection factor that is associated with a delay between generating asignal to actuate the tool to perform the function and performance ofthe function by the tool, and actuating the tool to perform the functionincludes actuating the tool to perform the function at a given timeafter detecting the given phase of the first motion cycle, the giventime being determined by subtracting the mechanical-delay correctionfactor from the duration of the motion cycle.

There is further provided, in accordance with some applications of thepresent invention, apparatus for use with a portion of a subject's bodythat undergoes a motion cycle, including:

a tool configured to perform a function on the portion of the subject'sbody; and

at least one processor, including:

-   -   cycle-measuring functionality configured to determine a duration        of the motion cycle;    -   phase-detection functionality configured, in a first motion        cycle of the subject, to detect the given phase of the subject's        motion cycle; and    -   tool-actuation functionality configured to actuate the tool to        perform the function at a given time after the detection of the        given phase of the first motion cycle, the given time being        determined by subtracting a correction factor from the duration        of the motion cycle.

There is additionally provided, in accordance with some applications ofthe present invention, a method for imaging a portion of a body of asubject that undergoes a motion cycle, the method including:

acquiring a plurality of image frames of the portion of the subject'sbody; and

enhancing the image frames with respect to a first given feature of theimage frames, by:

-   -   image tracking the image frames with respect to the first given        feature;    -   identifying a second given feature in each of the image frames;    -   in response to the identifying, reducing visibility of the        second given feature in the image frames; and

displaying, as a stream of image frames, the image frames that (a) havebeen image tracked with respect to the first given feature, and (b) havehad reduced therein the visibility of the second given feature.

For some applications, reducing the visibility of the second featureincludes reducing the visibility by a reduction factor that is afunction of a distance of the second feature from the first feature.

For some applications, reducing visibility of the second given featureincludes eliminating visibility of the second given feature.

For some applications, as a result of the motion cycle of the portion ofthe subject's body, the first given feature moves by an amount that isdifferent from an amount of movement of the second given feature as aresult of the motion cycle of the portion of the subject's body, andidentifying the second feature includes identifying the second featureusing a filter selected from the group consisting of a spatial filterand a temporal filter.

There is further provided, in accordance with some applications of thepresent invention, apparatus for use with a portion of a body of asubject that undergoes a motion cycle, the apparatus including:

an image-acquisition device configured to acquire a plurality of imageframes of the portion of the subject's body;

a display; and

at least one processor configured to enhance the image frames withrespect to a first given feature of the image frames, the processorincluding:

-   -   image-tracking functionality configured to image track the image        frames with respect to the first given feature;    -   feature-identifying functionality configured to identify a        second given feature in each of the image frames;    -   image-processing functionality configured, in response to the        identifying, to reduce visibility of the second given feature in        the image frames; and    -   display-driving functionality configured to drive the display to        display, as a stream of image frames, the image frames that (a)        have been image tracked with respect to the first given feature,        and (b) have had reduced therein the visibility of the second        given feature.

There is additionally provided, in accordance with some applications ofthe present invention, a method for imaging a portion of a body of asubject that undergoes a motion cycle, the method including:

acquiring a plurality of image frames of the portion of the subject'sbody;

reducing visibility of a given feature within the image frames bymasking the given feature in each of the image frames; and

displaying, as a stream of image frames, the image frames in which thegiven feature has reduced visibility.

For some applications:

masking the given feature in each of the image frames includesgenerating a plurality of masks, respective masks corresponding to givenphases of the motion cycle, and

applying the mask to the image frames includes applying to frames of theimage stream that were acquired during respective phases of the motioncycle, a corresponding mask.

For some applications:

acquiring the plurality of image frames includes gating the image frameswith respect to a given phase of the motion cycle,

masking the given feature in each of the image frames includesgenerating a mask based on an image frame that is gated with respect tothe given phase of the motion cycle, and applying the mask to the gatedimage frames, and

displaying the image frames includes displaying the gated, masked imageframes.

For some applications, reducing the visibility of the given featureincludes reducing the visibility in each of the image frames by areduction factor that is a function of a distance of the given featurefrom a given portion of the image frame.

There is further provided, in accordance with some applications of thepresent invention, apparatus for use with a portion of a body of asubject that undergoes a motion cycle, the apparatus including:

an image acquisition device configured to acquire a plurality of imageframes of the portion of the subject's body;

a display; and

at least one processor including:

-   -   image-receiving functionality configured to receive the image        frames into the processor, and    -   masking functionality that is configured to reduce visibility of        a given feature within the image frames by masking the given        feature in each of the image frames; and    -   display-driving functionality configured to drive the display to        display, as a stream of image frames, the image frames in which        the given feature has reduced visibility.

For some applications:

the processor includes gating functionality configured to gate the imageframes with respect to a given phase of the motion cycle,

the masking functionality is configured to generate a mask based on animage frame that is gated with respect to the given phase of the motioncycle, and to apply the mask to the gated image frames, and

the display-driving functionality is configured to drive the display todisplay the gated, masked image frames.

There is additionally provided, in accordance with some applications ofthe present invention, a method, including:

generating a road map of a blood vessel in a portion of a body of asubject;

identifying, in the road map, a given feature that is within the portionof the subject's body, the given feature being visible even in images ofthe portion the generation of which does not include use of a contrastagent;

inserting a tool into the blood vessel;

determining a current location of at least a portion of the tool withrespect to the given feature, by imaging the tool and the feature;

in response to the determined current location, determining a currentposition of the tool within the road map; and

in response to determining the current position of the tool within theroad map, displaying the current position of the tool with respect tothe road map.

For some applications, the tool includes a balloon, and inserting thetool includes inserting the balloon.

For some applications, the tool includes a replacement valve, andinserting the tool includes inserting the replacement valve.

For some applications, the tool includes a stent, and inserting the toolincludes inserting the stent.

For some applications, the tool includes a wire, and inserting the toolincludes inserting the wire.

For some applications, the tool includes a catheter, and inserting thetool includes inserting the catheter.

For some applications, generating the road map includes generating aroad map based upon a given phase of a motion cycle of the blood vessel,and determining the current location of the portion of the tool includesdetermining the current location of the portion of the tool during thegiven phase.

There is further provided, in accordance with some applications of thepresent invention, apparatus, including:

a tool configured to be inserted into a blood vessel of a portion of abody of a subject;

a display; and

at least one processor, including:

-   -   road-map-generation functionality configured to generate a road        map of the blood vessel in the portion of the subject's body;    -   feature-identifying functionality configured to identify, in the        road map, a given feature that is within the portion of the        subject's body, the given feature being visible even in images        of the portion the generation of which does not include use of a        contrast agent;    -   tool-location functionality configured to determine a current        location of at least a portion of the tool with respect to the        given feature, based on a current image of the tool and the        feature;    -   tool-positioning functionality configured, in response to the        determined current location of the tool, to determine a current        position of the tool within the road map; and    -   display-driving functionality configured, in response to        determining the current position of the tool within the road        map, to drive the display to display the current position of the        tool with respect to the road map.

There is additionally provided, in accordance with some applications ofthe present invention, a method, including:

generating a road map of a blood vessel in a portion of a body of asubject;

identifying, in the road map, a given feature that is within the portionof the subject's body, the given feature being visible even in images ofthe portion the generation of which does not include use of a contrastagent;

generating an image stream of the blood vessel;

identifying the given feature in the image stream;

registering the road map to the image stream using the identifiedfeature; and

in response to the registration of the road map to the image stream,overlaying the road map on the image stream.

There is further provided, in accordance with some applications of thepresent invention, apparatus, including:

a tool configured to be inserted into a blood vessel of a portion of abody of a subject;

an image-acquisition device configured to acquire an image stream of theblood vessel;

a display; and

at least one processor, including:

-   -   image-receiving functionality configured to receive the image        stream into the processor;    -   road-map-generation functionality configured to generate a road        map of the blood vessel in the portion of the subject's body;    -   road-map-feature-identifying functionality configured to        identify, in the road map, a given feature that is within the        portion of the subject's body, the given feature being visible        even in images of the portion the generation of which does not        include use of a contrast agent;    -   image-stream-feature-identifying functionality configured to        identify the feature in the image stream;    -   registration-functionality configured to register the road map        to the image stream using the identified feature; and    -   display-driving functionality configured, in response to the        registration of the road map to the image stream, to drive the        display to overlay the road map on the image stream.

There is additionally provided, in accordance with some applications ofthe present invention, a method for use with a portion of a subject'sbody that assumes a plurality of different shapes, during respectivephases of a motion cycle of the portion, the method including:

acquiring a plurality of image frames of the portion of the subject'sbody during the respective phases of the motion cycle of the portion;

designating at least one of the image frames as a baseline image frame,a shape of the portion in the baseline image frame being designated as abaseline shape of the portion;

identifying a non-baseline image frame of the plurality of image frames,by identifying an image frame in which the portion is not shaped in thebaseline shape; and

deforming the shape of the portion in the non-baseline image frame, suchthat the shape of the portion becomes more similar to the baseline shapeof the portion than when the portion in the non-baseline image frame isnot deformed; and

subsequently to deforming the shape of the portion in the non-baselineimage frame, displaying the baseline image frame and the non-baselineimage frame in an image stream.

There is further provided, in accordance with some applications of thepresent invention, apparatus for use with a portion of a subject's bodythat assumes a plurality of different shapes, during respective phasesof a motion cycle of the portion, the apparatus including:

an image-acquisition device configured to acquire a plurality of imageframes of the portion of the subject's body during the respective phasesof the motion cycle of the portion;

a display; and

at least one processor, including:

-   -   image-receiving functionality configured to receive the image        frames into the processor,    -   baseline-designation functionality configured to designate at        least one of the image frames as a baseline image frame, a shape        of the portion in the baseline image frame being designated as a        baseline shape of the portion;    -   non-baseline identification functionality configured to identify        a non-baseline image frame of the plurality of image frames, by        identifying an image frame in which the portion is not shaped in        the baseline shape; and    -   shape-deformation functionality configured to deform the shape        of the portion in the non-baseline image frame, such that the        shape of the portion becomes more similar to the baseline shape        of the portion than when the portion in the non-baseline image        frame is not deformed; and    -   display-driving functionality configured, subsequently to the        deforming of the shape of the portion in the non-baseline image        frame, to drive the display to display the baseline image frame        and the non-baseline image frame in an image stream.

There is additionally provided, in accordance with some applications ofthe present invention, a method for deploying an implantable tool at animplantation location of a blood vessel of a subject, including:

placing the tool at the implantation location, while the tool is in anon-deployed configuration;

while the tool in the non-deployed configuration is disposed at theimplantation location, acquiring a plurality of image frames of thetool, during respective phases of a motion cycle of the blood vessel;

generating a stabilized image stream of the tool in the non-deployedconfiguration, by stabilizing the plurality of image frames;

determining from the stabilized image stream that, during the motioncycle of the blood vessel, the tool moves from the implantation locationby a given distance in a first direction; and

accounting for the movement of the tool by the given distance, bydeploying the tool at a deployment location that is distant from theimplantation location in a second direction, the second direction beingan opposite direction to the first direction.

For some applications, accounting for the movement of the tool by thegiven distance includes deploying the tool at a deployment location thatis at the given distance from the implantation location in the seconddirection.

For some applications, accounting for the movement of the tool by thegiven distance includes deploying the tool at a deployment location thatis at a distance from the implantation location in the second directionthat is greater than the given distance.

For some applications, accounting for the movement of the tool by thegiven distance includes deploying the tool at a deployment location thatis at a distance from the implantation location in the second directionthat is less than the given distance.

For some applications, the tool includes a tool selected from the groupconsisting of a stent, a replacement valve, and a graft, and placing thetool at the implantation location includes placing the selected tool atthe implantation location.

There is further provided, in accordance with some applications of thepresent invention, apparatus for deploying, including:

an implantable tool configured to be placed at an implantation locationof a blood vessel of a subject, while the tool is in a non-deployedconfiguration;

an image acquisition device configured, while the tool is disposed atthe implantation location in a non-deployed configuration, to acquire aplurality of image frames of the tool, during respective phases of amotion cycle of the blood vessel;

a display; and

-   -   at least one processor, including:    -   image-stabilization functionality configured to generate a        stabilized image stream of the tool in the non-deployed        configuration, by stabilizing the plurality of image frames;    -   motion-determination functionality configured to determine based        on the stabilized image stream that, during the motion cycle of        the blood vessel, the tool moves from the implantation location        by a given distance in a first direction; and    -   deployment-location functionality configured to determine a        deployment location for the tool that is distant from the        implantation location in a second direction, by accounting for        the movement of the tool by the given distance, the second        direction being an opposite direction to the first direction;        and    -   display-driving functionality configured to drive the display to        display an output indicating the deployment location.

The present invention will be more fully understood from the followingdetailed description of embodiments thereof, taken together with thedrawings, in which:

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a flow chart, at least some of the steps of which are used toautomatically generate a road map, in accordance with some applicationsof the present invention;

FIG. 2 shows a baseline image that was used in the automatic generationof a road map, in accordance with some applications of the presentinvention;

FIG. 3 shows an image frame during the commencement of an angiographicsequence that was used in the automatic generation of a road map, inaccordance with some applications of the present invention;

FIG. 4 shows an angiographic image (i.e., an angiogram) that was derivedfrom a set of angiograms, some blood vessels appearing highlighted inthe image, in accordance with some applications of the presentinvention;

FIG. 5 shows center lines constructed automatically along a portion ofthe blood vessels, in accordance with some applications of the presentinvention;

FIG. 6 shows end points at discontinuities in the center lines that wereidentified automatically, in accordance with some applications of thepresent invention;

FIG. 7 shows gaps between end points in the center lines having beenbridged automatically, in accordance with some applications of thepresent invention;

FIG. 8 shows edge-lines (i.e., boundaries) of the blood vessels, whichwere detected automatically, in accordance with some applications of thepresent invention;

FIG. 9 shows a road map in which the markers of a balloon situatedwithin an artery are visible, in accordance with some applications ofthe present invention;

FIG. 10 shows distance indicators on a road map, in accordance with someapplications of the present invention;

FIG. 11 shows an image in which a guiding catheter has been segmented,in accordance with some applications of the present invention;

FIG. 12 shows an automatically-generated road map, overlaid upon theangiogram from which it was generated, in accordance with someapplications of the present invention;

FIG. 13 shows an automatically-generated road map, overlaid upon animage frame belonging to a stabilized image stream, in accordance withsome applications of the present invention;

FIG. 14 shows a road map displayed side-by-side with a stabilizedfluoroscopic image stream, edge lines of the road-map also beingoverlaid upon the fluoroscopic image stream, in accordance with someapplications of the present invention;

FIG. 15 shows a region of interest marked on a road map, in accordancewith some applications of the present invention;

FIG. 16 is a schematic illustration of a screen on which quantitativevessel analysis (QVA) is displayed with respect to a segment of a vesselthat is part of a road map, in accordance with some applications of thepresent invention;

FIGS. 17A-B are schematic illustrations of a screen displaying QVA datawith respect to a segment of a vessel that is part a selectedangiographic image, in accordance with some applications of the presentinvention;

FIG. 18 shows QVA diameter diagrams, in accordance with someapplications of the present invention;

FIG. 19 shows a QVA diagram, comprising a representation of a tool atits relative location within the lesion on which QVA has been performed,in accordance with some applications of the present invention;

FIG. 20 shows a road map that displays measurements of the diameter ofthe reference artery at both sides of an occlusion, in accordance withsome applications of the present invention;

FIG. 21 shows markers of a balloon that are highlighted during at leastone given phase of the cardiac cycle, in accordance with someapplications of the present invention;

FIG. 22 shows two stabilized images of markers of a balloon inside anartery, at respective phases of the cardiac cycle, in accordance withsome applications of the present invention;

FIG. 23A shows a balloon being inflated inside a stent, there beingoverhanging regions at ends of the balloon that are inflated insynchronization with the subject's cardiac cycle, in accordance withsome applications of the present invention;

FIGS. 23B-C show apparatus for facilitating synchronized inflation of aballoon, in accordance with some applications of the present invention;

FIG. 24 shows an image of an inflated coronary balloon that is enhanced,in accordance with some applications of the present invention;

FIG. 25 shows an image of a deployed coronary stent that wasautomatically enhanced, alongside a raw image of the stent, inaccordance with some applications of the present invention;

FIG. 26 shows an image stream that was tracked and enhanced, displayedside by side with a native image stream, in accordance with someapplications of the present invention;

FIG. 27 shows an image stream that was tracked and enhanced, displayedside by side with a recent angiographic image frame, in accordance withsome applications of the present invention;

FIG. 28 is a flow chart of a sequence of steps, one or more of which maybe performed in a coronary angioplasty procedure, in accordance withsome applications of the present invention;

FIG. 29 is a flow chart of a sequence of steps, one or more of which maybe performed in a coronary angioplasty procedure, in accordance withsome applications of the present invention;

FIG. 30 is a flow chart of a sequence of steps of a percutaneous aorticvalve replacement (PAVR) procedure, in accordance with some applicationsof the current invention;

FIG. 31 shows a road map of the ascending aorta, in accordance with someapplications of the present invention;

FIG. 32 shows the road map of the ascending aorta overlaid upon afluoroscopic image stream of the corresponding anatomy, in accordancewith some applications of the present invention;

FIGS. 33A and 33B show radiopaque markers of a transapical valvedelivery device and of a transfemoral pigtail catheter, which areautomatically identified, in accordance with some applications of thepresent invention;

FIG. 34 shows a valve, which is graphically illustrated based on itsknown location relative to a radiopaque valve delivery device, inaccordance with some applications of the present invention;

FIG. 35 shows an image of a pre-deployed graphically illustrated valvepositioned upon a stabilized image stream on which a road map has beenoverlaid, in accordance with some applications of the present invention;

FIG. 36 shows a graphically illustrated expanded valve deployed withinthe ascending aorta, in accordance with some applications of the presentinvention; and

FIGS. 37A and 37B show measurements performed upon a valve deployed inthe ascending aorta, in accordance with some applications of the presentinvention.

DETAILED DESCRIPTION OF EMBODIMENTS Terminology

-   As used herein:    -   The term “physiological signal or process” refers to any        physiological signal or process of the subject's body including,        but not limited to, ECG (also known as EKG), blood pressure        (e.g., systolic and diastolic), Peripheral Arterial Tone (PAT),        EEG, respiration, the        shifting/expansion/contraction/displacement of an organ,        acquired images in which any of the above signals or processes        may be observed, or any combination, derivation, extrapolation        or manipulation thereof.

(Typically, a physiological signal or process as described herein iscyclical.)

-   -   The terms “medical tool,” “tool”, “device,” and “probe” refer to        any type of a diagnostic or therapeutic or other functional tool        including, but not limited to, a cardiovascular catheter, a        stent delivery and/or placement and/or retrieval tool, a balloon        delivery and/or placement and/or retrieval tool, a valve        delivery and/or repair and/or placement and/or retrieval tool, a        graft delivery and/or placement and/or retrieval tool, a tool        for the delivery and/or placement and/or retrieval of an        implantable device or of parts of such device, an implantable        device or parts thereof, a tool for closing a gap, a tool for        closing a septal defect, a guide wire, a marker wire, a suturing        tool, a clipping tool (such as a valve-leaflet-clipping tool), a        biopsy tool, an aspiration tool, a navigational tool, a        localization tool, a probe comprising one or more location        sensors, a tissue characterization probe, a probe for the        analysis of fluid, a measurement probe, an electrophysiological        probe, a stimulation probe, an ablation tool, a tool for        penetrating or opening partial or total occlusions in blood        vessels, a drug or substance delivery tool, a chemotherapy tool,        a photodynamic therapy tool, a brachytherapy tool, a local        irradiation tool, a laser device, a tool for delivering energy,        a tool for delivering markers or biomarkers, a tool for        delivering biological glue, an irrigation device, a suction        device, a ventilation device, a device for delivering and/or        placing and/or retrieving a lead of an electrophysiological        device, a lead of an electrophysiological device, a pacing        device, a coronary sinus device, an imaging device, a sensing        probe, a probe comprising an optical fiber, a robotic tool, a        tool that is controlled remotely, or any combination thereof.    -   The terms “image” and “imaging” refer to any type of medical        imaging, typically presented as a sequence of images and        including, but not limited to, imaging using ionizing radiation,        imaging using non-ionizing radiation, video, fluoroscopy,        angiography, ultrasound, CT, MRI, PET, PET-CT, CT angiography,        SPECT, Gamma camera imaging, Optical Coherence Tomography (OCT),        Near-Infra-Red Spectroscopy (NIRS), Vibration Response Imaging        (VRI), Optical Imaging, infrared imaging, electrical mapping        imaging, other forms of Functional Imaging, or any combination        or fusion thereof. Examples of ultrasound imaging include        Endo-Bronchial Ultrasound (EBUS), Trans-Thoracic Echo (TTE),        Trans-Esophageal Echo (TEE), Intra-Vascular Ultrasound (IVUS),        Intra-Cardiac Ultrasound (ICE), or any combination thereof.    -   The term “contrast agent,” when used in reference to its        application in conjunction with imaging, refers to any substance        that is used to highlight, and/or enhance in another manner, the        anatomical structure, functioning, and/or composition of a        bodily organ while the organ is being imaged.    -   The term “stabilized,” when used in the context of displayed        images, means a display of a series of images in a manner such        that periodic, cyclical, and/or other motion of the body        organ(s) being imaged, and/or of a medical tool being observed,        is partially or fully reduced, with respect to the entire image        frame, or at least a portion thereof.    -   The terms “synchronization” and “gating,” and derivations        thereof, when used in reference to an image stream, describe the        identification and selection of individual image frames from        such image stream, wherein such frames are acquired at a same        selected phase in a plurality of occurrences of a cyclical        physiological signal or process.    -   The terms “gating” and “synchronization,” and derivations        thereof, when used in the context of synchronizing between an        image display and one or more physiological signals or        processes, or between the activation of a medical tool and one        or more physiological signals or processes, are interchangeable.        (The term “coherence” and derivations thereof are also used in        the art to describe such techniques.)    -   The terms “gating” and “synchronization,” and derivations        thereof, when used in reference to a medical tool, describes the        movement and/or application of the tool at a given phase of a        cyclical physiological signal or process.    -   The terms “image tracking” or “tracking,” and derivations        thereof, are used to describe a process by which images        (including images acquired at different phases in the motion of        an organ) are at least partially aligned with one another by        means of aligning among such images one or more features, that        are observable in most or all of the images. Such features may        be anatomical features, such as a segment of a vessel. Such        features may also be physical features, such as a tool or a        segment of a tool. For some applications, the alignment of the        image frames is achieved by aligning a virtual feature or region        that is derived from a manipulation (such as an average, a        weighted average, a translation, a rotation, and/or a scaling)        of the locations of one or more observable features or regions        of the image frames. The term should be construed to be        synonymous with the terms “video tracking,” “frame tracking,”        and “object tracking” Tracking may be applied for the purpose of        image stabilization, image enhancement, or a combination        thereof.    -   The term “automatic,” when used for describing the generation        and utilization of the road map, means “without necessitating        user intervention or interaction.” (Such interaction or        intervention may still however be optional in some cases.)    -   The term “real time” means without a noticeable delay.    -   The term “near real time” means with a short noticeable delay        (such as approximately one or two motion cycles of the        applicable organ, and, in the case of procedures relating to        organs or vessels the motion of which are primarily as a result        of the cardiac cycle, less than two seconds).    -   The term “on-line,” when used in reference to image processing,        or to measurements being made on images, means that the image        processing is performed, and/or the measurements are made,        intra-procedurally, in real time or near real time.    -   The term “stepwise,” when used in reference to the actuation of        a tool, should be interpreted as “in two or more steps which are        separated in time.”    -   The term “image stream” should be interpreted to mean the        display of at least five image frames at a frame rate such that        the image frames in effect show a movie of a portion of a        subject's body undergoing at least one entire motion cycle. An        image stream of a portion of a subject's body undergoing a        motion cycle typically has a frame rate of at least 1 frame per        motion cycle. In the case of a cardiac motion cycle, therefore,        the image stream typically has a frame rate of at least 0.5 Hz        (for a slow heart rate). In the case of cardiac and non-cardiac        motion cycles, the frame rate is typically 1-10 frames per        motion cycle, or higher.

Identification of Vessel Boundaries and the Generation of a Road Map

Reference is now made to FIG. 1, which is a flow chart, at least some ofthe steps of which are used to automatically generate a road map, inaccordance with some applications of the present invention. Theautomatic generation of a road map is described with reference tocoronary angiography, by way of example. The scope of the presentinvention includes the automatic generation of a road map using adifferent imaging modality.

In Phase 1 of the automatic road map generation, a fluoroscopic imagestream of the coronary arteries is acquired. Typically, during theacquisition of the image stream, a contrast agent is administered to thesubject. Optionally, the image stream is gated, tracked, and/orstabilized by other means. For example, selected image framescorresponding to a given phase in the motion cycle of the heart may beidentified by means of a physiological signal. For some applications,the physiological signal applied is the subject's ECG and the imageframes are selected by means of gating to the ECG and/or by other meansof gating as described in WO 08/107905 to Iddan, which is incorporatedherein by reference. It is noted that stabilization of the image streamis optional and, for some applications, a road map is automaticallygenerated on a native (non-stabilized) fluoroscopic image stream.

For some applications, the ECG signal is received from an ECG monitor.Alternatively or additionally, the ECG signal is received from a CardiacRhythm Management (CRM) device such as a pacer, or a defibrillator. Forsome applications, a processor that performs the automatic generation ofthe road map, or a dedicated processor, identifies the selected phase ofthe ECG signal. (In general, in the present application, when referencesare made to the functionalities of a processor, the functionalities maybe performed by a single processor, or by several processors, which act,effectively, like a single processor with several functionalities.)Alternatively, the selected phase (e.g., the R wave of the ECG signal)is identified by the ECG monitor. Further alternatively, the selectedphase (e.g., the R wave of the ECG signal) is identified by the CRMdevice.

For some applications, image tracking is applied to the native imagestream, with respect to a guiding catheter or with respect to a segmentof the guiding catheter, as described in further detail hereinbelow. Forexample, the native image stream may be image tracked with respect tothe distal tip of the guiding catheter, e.g., a curved portion of theguiding catheter. Alternatively or additional, image tracking isperformed with respect to one or more radiopaque (or otherwise visible)markers or segments of a tool. For some applications, image tracking, oralternative techniques for stabilizing the image stream, is performedwith respect to a virtual feature or region of image frames of thenative image stream. Such virtual features are typically derived from amanipulation (such as an average, a weighted average, a translation, arotation, and/or a scaling) of the location of one or more observablefeatures of the image. For example, the virtual feature may be theaverage location of two radiopaque markers of a balloon.

In Phase 2 of the automatic road map generation, a baseline fluoroscopicimage frame is identified, typically automatically, the baseline imageframe having been acquired prior to the contrast agent having beenadministered to the subject. (For some applications, the baseline frameis selected manually by the user.) For some applications, the baselineimage frame is gated to a given phase of the subject's cardiac cycle(i.e., it selected based on its having been acquired at the given phaseof the subject's cardiac cycle). Typically, the baseline image is animage frame that is generated immediately before the contrast agent was(or is about to be) administered to the subject (as described in furtherdetail hereinbelow).

For some applications, the baseline image frame is used a referenceimage frame, to which to compare subsequent image frames, in order todetermine when an angiographic sequence has commenced, as describedhereinbelow. Alternatively or additionally, techniques such as thetechniques described hereinbelow are used for determining thecommencement or the end of an angiographic sequence, not by comparingimage frames to the baseline image frame, but by detecting rapid changesin parameters of image frames of the image stream. For example, in orderto determine when an angiographic sequence has commenced, a vesselnessdescriptor may be calculated for each image in the image stream. Thevesselness descriptor is typically calculated in accordance with thetechniques described hereinbelow. For example, the vesselness descriptormay be calculated by counting a number of possible centerline points ofa vessel in each of the images that are located near to possible edgelines of the vessel. Commencement of an angiographic sequence isdetermined by detecting a rapid increase in the vesselness descriptor.The end of an angiographic sequence is determined by detecting a rapiddecrease in the vesselness descriptor.

For some applications, the baseline image frame is analyzed such thatthe degree of “vesselness” (i.e., the extent to which a given pixel islikely to be an element of an image of a vessel) in applicable areas ofthe image frame is determined. For example, vesselness may be determinedby means of a filter, such as the filter described in the article byFrangi (a “Frangi filter”), cited hereinabove, which is incorporatedherein by reference, and/or by means of a filter that performsenhancement and/or detection and/or segmentation of curvilinearstructures. For some applications, a filter is used that is similar to aFrangi filter, but that differs from a Frangi filter (“a Frangi-likefilter”) (a) in that vesselness is a homogeneous function, and/or (b) inthe multipliers employed for the normalization of scales.

Reference is now made to FIG. 2, which shows a baseline image that wasused in the automatic generation of a road map, in accordance with someapplications of the present invention. A guiding catheter 12, throughwhich a catheter of a non-inflated balloon 10 is inserted, may beobserved.

In Phase 3 of the automatic road map generation, an identification ordetection is typically provided that angiography has commenced or isabout to commence. For example, commencement of the angiography may bedetected by detecting the injection of contrast agent, and/or bydetecting the activation of a special imaging mode such as cine. Forsome applications, several angiographic sequences are acquired and thecommencement of each of the angiographic sequences is detected, in orderto separate the angiographic sequences from one another. Typically, theangiographic sequences are separated from each other such that the mostsuitable image frame for generating a new road map is selected only fromamong the frames belonging to the most recent angiographic sequence.

For some applications, the identification that angiography hascommenced, or is about to commence, is provided automatically by theapparatus for injecting the contrast agent. Alternatively oradditionally, the identification that angiography has commenced, or isabout to commence, is provided manually by the operator of the apparatusinjecting the contrast agent. Further alternatively or additionally, theidentification that angiography has commenced is provided automaticallyby identifying that in the acquired image frames there is an increasedportion or count of vessel-like pixels. For example, such automaticidentification may be provided by means of a filter that performsenhancement and/or detection and/or segmentation of curvilinearstructures, a Frangi filter, and/or a Frangi-like filter. For someapplications, the commencement of an angiographic sequence is detectedby detecting the appearance of temporarily-appearing vessel-likefeatures. Typically, the detection of temporarily-appearing vessel-likefeatures indicates a new angiographic sequence.

For some applications, the identification that angiography has commencedis provided automatically by means of image processing, as described inWO 08/107905 to Iddan, which is incorporated herein by reference.Suitable image processing techniques include the analysis of changes inthe current image, and/or, specifically, changes in the image region atthe distal end of the catheter from which the contrast agent enters thesubject's vasculature (such as a guiding catheter in the case ofcoronary road mapping). For example, changes in the image may include arelatively abrupt change in the color and/or grayscale level (i.e.,darkness) of a relatively large number and/or portion of image pixels,or the appearance of vessel-like features in the image, or anycombination thereof. It is noted that by assessing a change in thedarkness level to identify the time of injection of the contrast agent,the automatic road map generation processor may identify a darker areaof the image or a lighter area of the image, depending on whether thecontrast agent is represented as dark or light.

For some applications, the identification that angiography has commencedis performed by comparing a current image frame to the baseline imageframe. Alternatively, the identification that angiography has commencedis performed not by comparing image frames to the baseline image frame,but by detecting rapid changes in parameters of image frames of theimage stream.

For some applications, the identification that angiography has commencedis accelerated by reducing the resolution of the image frames, andapplying image processing techniques to the reduced-resolution imageframes.

It is noted that whereas specifically assessing the region at the distalend of the catheter typically enhances signal to noise (because thisregion is most likely to show an abrupt change), the scope of thepresent invention includes assessing most or all of the acquired imagedata to identify the injection of the contrast agent.

Reference is now made to FIG. 3, which shows an image frame during thecommencement of an angiographic sequence that was used in the automaticgeneration of a road map, in accordance with some applications of thepresent invention. A cloud 14 of contrast agent may be observed in thevicinity of the distal tip of guiding catheter 12.

In Phase 4 of the automatic road map generation, an identification ordetection is typically provided that the acquisition of image frames inthe presence of contrast agent has ended or subsided. That is to say,the contrast agent injected into the coronary arteries has dissipated(or mostly dissipated) such that it is generally no longer visible inthe fluoroscopic images. For some applications, such identification isprovided automatically by apparatus that injects the contrast agent,and/or is provided manually by the operator of the apparatus injectingthe contrast agent. For some applications, such identification ordetection is provided by identifying decreased vesselness, for example,by means of a filter that performs enhancement and/or detection and/orsegmentation of curvilinear structures, a Frangi filter, and/or aFrangi-like filter. Alternatively or additionally, such identificationor detection is provided automatically by image processing techniquessimilar to those described with reference to Phase 3 above.

For some applications, and as an alternative to Phase 4, the end of asequence of angiographic images is assumed after a certain period oftime has elapsed since the commencement of the angiographic sequence.The period of time typically corresponds to the typical duration of anangiographic sequence.

In Phase 5 of the automatic generation of the road map, the angiographicimage frames (also known as angiograms) corresponding to a givenangiographic sequence are automatically analyzed, such that an angiogramis derived (e.g., selected) from the set of angiograms, based uponvisibility of at least a portion of the blood vessels in the angiograms.For some applications, the angiogram with the greatest visibility ofcoronary arteries is selected, with such selection typically beingautomatic. The greatest visibility is typically determined based uponthe greatest total number of arteries observed, the greatest number ofimage pixels attributed to an artery, and/or the greatest image contrastin the appearance of specific arteries. Such an angiogram with thegreatest visibility of coronary arteries is typically the most suitablefor serving as the basis for the most informative road map in situationswherein the greatest amount of vasculature should be observed.

For some applications, an aggregated image of two or more angiograms isderived from the sequence of angiograms. For example, two or moreangiograms that provide the greatest visibility of the coronary arteriesare added to each other. Alternatively, a portion of a first angiogramthat provides good visibility of a first portion of the coronaryarteries is aggregated with a portion of a second angiogram thatprovides good visibility of a second portion of the coronary arteries.

For some applications, an angiogram having the greatest visibility ofthe coronary arteries is identified by means of vesselness of imagepixels. Alternatively or additionally, such vesselness is determined bymeans of a filter, such as a filter that performs enhancement and/ordetection and/or segmentation of curvilinear structures, a Frangifilter, and/or a Frangi-like filter. For some applications, thedetermination of vesselness of image pixels is made with reference toknown anatomical structures, and/or with reference to known anatomy ofthe specific subject. For some applications, the determination ofvesselness of image pixels is made while accounting for the specificviewing angle at which the images are generated.

For some applications, only angiograms belonging to the angiographicsequence that are gated to a given phase of the cardiac cycle areanalyzed. An angiographic image frame is derived (e.g., selected) fromthe gated angiograms, based upon visibility of at least a portion of theblood vessels in the angiograms. For example, the gated angiogram withthe greatest visibility of coronary arteries may be selected. For someapplications, the given cardiac phase is an end-diastolic phase, atwhich certain coronary vessels are typically the most spread apart.

For some applications, the end-diastolic phase is identified by means ofimage processing (and not, or not exclusively, by means of gating to theECG signal). For example, an image in which distances between coronaryvessels are largest may be identified, and/or a degree of vesselnesswithin a region of interest may be analyzed. For some applications, animage frame in which motion of coronary blood vessels is at a minimum,as would typically be expected during end-diastole, is identified.

For some applications, limiting the derivation of the angiogram to onlyamong angiograms gated to a specific cardiac phase is suitable when theoperator's interest is focused on the specific phase. Typically, forsuch applications, the operator will designate the phase with respect towhich the angiograms are gated via an input device. For someapplications, only angiograms sampled at a defined time interval (e.g.,every 100 ms, or between the 700th ms and 1000th ms of every second),and/or at a defined sequential interval (e.g., every fifth frame, orbetween the 10th and 15th of every 15 frames), are analyzed. For someapplications, frames sampled within the time interval are gated, and/orframe(s) with the highest vesselness are identified from among framessampled within the time interval.

Reference is now made to FIG. 4, which shows an angiographic image(i.e., an angiogram) that was derived from a set of angiograms, someblood vessels 16 appearing highlighted (i.e., demonstrated) in theimage, in accordance with some applications of the present invention.

In Phase 6 of the automatic road map generation, designated vessels inthe selected angiogram(s) are enhanced, typically automatically. Forsome applications, low-contrast vessels that are typically lessobservable in the non-enhanced image, and/or narrow vessels that aretypically less observable in the non-enhanced image, are detected andenhanced. For some applications, non-vascular structures whose spatialand/or temporal characteristics differ from those of vascular structuresare identified, and the visibility of such structures is reduced. Forexample, such spatial characteristics may include dimensions, relativelocation, gray level, texture, edge smoothness, or any combinationthereof, and such temporal characteristics may include relative motion,absolute motion, and/or a change over time of any of any of theaforementioned spatial characteristics. For some applications, theenhancement is performed by means of a filter that detects and/orsegments curvilinear structures. Alternatively or additionally, theenhancement is performed by means of a Frangi-filter, such that vesselsand their local orientation are automatically detected by analyzingeigenvalues and eigenvectors of the Hessian matrix of a smoothed image.

In Phase 7 of the automatic road map generation, the darkest lines, orthe center lines, or any other characterizing or representative linescorresponding to paths of one or more designated blood vessels aredetermined, typically automatically. For some applications, the pointscomprising such lines are determined by means of their relatively highvalue of vesselness. Alternatively or additionally, the pointscomprising such lines are determined by the extent to which theirgradient is orthogonal to the eigenvector of the Hessian matrixcorresponding to the highest eigenvalue. For some applications, suchdetermination is assisted by a voting function applied to points thatare adjacent to those points that are eventually determined toconstitute the center line itself.

For some applications, thresholding is applied to image pixels by meansof hysteresis. For example, pixels the vesselness value of which fallsbelow the high threshold of the hysteresis, but yet above the lowthreshold of the hysteresis, are incorporated into a line if they arecontiguous with pixels that fall at or above the high threshold of thehysteresis.

For some applications, the points which form the aforementioned linesare determined by means of morphological operations. For example, suchmorphological operations may include the skeletonization of athresholded vesselness image. For some applications, the thresholdapplied is adaptive according to the specific region in the image.

Reference is now made to FIG. 5, which shows center lines 18 constructedautomatically along a portion of the blood vessels, in accordance withsome applications of the present invention. The center lines are shownoverlaid upon the angiogram from which they were constructed.

Reference is now made to FIG. 6, which shows end points 20 (shown asstars) at discontinuities in center lines 18 that were identifiedautomatically, in accordance with some applications of the presentinvention. In Phase 8 of the automatic road map generation, which isapplicable in cases in which there are discontinuities within a centerline (or any other characterizing or representative line) of adesignated vessel, such discontinuities are bridged, typicallyautomatically. For some applications, end points are identifiedautomatically at both sides of a discontinuity. For some applications,bridging is performed across gaps between end points by means of ashortest-path algorithm, for example the shortest-path algorithmdescribed in the article by Dijkstra, which is cited hereinabove, andwhich is incorporated herein by reference. For some applications,bridging is performed subsequent to the detection of edges (i.e.,boundaries), corresponding to each already-determined segment of thecenter lines, i.e., subsequent to Phase 9 of the automatic road mapgeneration, described hereinbelow.

For some applications, bridging is performed across gaps between endpoints by means of an algorithm that takes into account the directionalvectors of the lines at both sides of the discontinuity. Alternativelyor additionally, the bridging is performed with reference to knowntypical structures of the coronary tree. For example, bridging may beperformed based upon what is typical at the corresponding section of acoronary tree.

For some applications, the bridging of gaps is performed with referenceto known structures of the coronary tree of the particular subject whois being imaged. Typically, in such cases, gaps are bridged based uponwhat has been previously observed, by means of imaging a correspondingsection of the subject's coronary tree. In accordance with respectiveapplications, the imaging modality used to image the correspondingsection of the subject's coronary tree is the same as the modality thatis used to generate the angiograms, or is a different imaging modality(for example, pre-operative CT) from the imaging modality used togenerate the angiograms (for example, fluoroscopy).

For some applications, the bridging of gaps is made while accounting forthe specific viewing angle at which the images are generated.

Reference is now made to FIG. 7, which shows bridges 22 in gaps betweenend points in center lines 18, the bridges having been generatedautomatically, in accordance with some applications of the presentinvention.

In Phase 9 of the automatic road map generation, the boundaries (i.e.,edges or edge lines) of one or more designated vessels are determined,typically automatically. For some applications, such boundaries aredetermined by means of region-based adaptive thresholding of thevesselness image. Alternatively or additionally, such boundaries aredetermined by means of a region-growing algorithm. Further alternativelyor additionally, such boundaries are determined by means of an edgedetector, and/or by means of a morphological operation. For someapplications, such boundaries are determined by means of a watershedtechnique, which splits an image into areas, based on the topology ofthe image. Alternatively or additionally, such boundaries are determinedby means of a live contour, and/or by means of matching filters.

For some applications, the determination of boundaries is made withreference to known typical structures of the coronary tree. Typically,in such cases, boundaries are determined in certain vessel segmentsbased upon what is typical at the corresponding section of a coronarytree.

For some applications, the determination of boundaries is made withreference to structures of the coronary tree of the specific subject.Typically, boundaries are generated based upon what has been previouslyobserved, by means of imaging a corresponding section of the subject'scoronary tree. In accordance with respective applications, the imagingmodality used to image the corresponding section of the subject'scoronary tree is the same as the modality that is used to generate theangiograms, or is a different imaging modality (for example,pre-operative CT) from the modality used to generate the angiograms (forexample, fluoroscopy).

For some applications, the boundaries are determined by means of adynamic programming approach, optimizing a penalty function. Forexample, the penalty function may be based upon image derivatives alongdirections perpendicular to the center line, and/or the distance fromthe center line.

For some applications, center lines are determined for the vesselsidentified in most of, or the entire, image frame, while boundaries areonly determined for specific vessels or sections of vessels. Forexample, boundaries of specific vessels may be determined upon the userindicating, typically by means of an input device, a region of interestor a specific vessel of interest or a specific section of such vessel.

For some applications, the determination of boundaries is made whileaccounting for the specific viewing angle at which the images aregenerated.

Reference is now made to FIG. 8, which shows edge-lines 24 (i.e.,boundaries) of blood vessels, which were detected automatically, inaccordance with some applications of the present invention.

For some applications, the system automatically validates apoint/segment as being part of the center line, and points/segments asbeing part of edge lines at sides of the center line, bycross-referencing the center line points/segments and edge linepoints/segments with respect to each other. For example, at each side ofa potential center line, an edge the gradient of which is perpendicular,or almost perpendicular, to that of the center line is selected suchthat the two gradients are in opposite directions and leading away fromthe center line. Typically, such validation is used for the eliminationof inappropriate center lines (or pixels attributed to such lines)and/or edge lines (or pixels attributed to such lines) and for theselection of those that are most appropriate.

For some applications, and typically subsequently to the aforementionedvalidation of matching between center lines and edge lines, missingpoints/sections in center lines are deduced and added. For someapplications, vectors obtained from a Frangi-like filter are appliedfrom known points at both sides of a gap in a center line and into thegap. Such vectors are local and typically are applied incrementally witheach increment based upon a new local computation, until the gap istypically eliminated.

For some applications, and typically subsequently to the aforementionedvalidation of matching between center lines and edge lines, missingpoints/sections in edge lines are deduced and added. For someapplications, sets of edge points are selected at both sides of a gap. Adynamic programming approach, optimizing a penalty function, is thenapplied to fill in the gap by proposing additional edge points, thedistances from the center line of which edge points are typicallysimilar to those of the adjacent, already-known edge points. The processis typically applied continuously until the gap in the edge line isbridged.

For some applications, the road map includes an image or contour of atool that was situated within one of the blood vessels at the time ofthe angiogram. Alternatively or additionally, the road map includesmarkers, and/or a graphical representation of markers, of a tool thatwas situated, at the time of the angiogram, within one of the bloodvessels. For example, the road map may include, in addition to theboundaries of the vessel, small circles indicating the positions of themarkers of a coronary balloon while such balloon was situated within thevessel at the time the angiogram was taken.

Reference is now made to FIG. 9, which shows a road map in which markers26 of a balloon situated within an artery are visible, in accordancewith some applications of the present invention.

For some applications, generation of the road map is intra-procedural.For example, the road map may be automatically generated in real time,or in near real time relative to the end of the angiographic segment.Alternatively, the automatic generation of the road map ispost-procedural.

It is noted that, for some applications, not all of the steps shown inFIG. 1 are performed for the automatic generation of the road map.

Generation of Distance Indicators

Reference is now made to FIG. 10, which shows distance indicators 28 ona road map, in accordance with some applications of the presentinvention. For some applications, a road map is generated that includesdistance indicators (e.g., notches) placed along or across a designatedvessel or a section thereof. For example, the indicators may be placedin order to show the length or the diameter of the vessel or sectionthereof. For some applications, the distance indicators are generatedautomatically.

For some applications, distance indicators are longitudinal, and areplaced along a borderline, and/or along a center line (or any othercharacterizing or representative line) of a designated vessel. For someapplications, segments of a designated vessel are marked in differentcolors corresponding to distances.

For some applications, the distances between the distance indicators areknown. For example, the distances between the indicators may bedetermined based upon some known anatomical feature, or based upon aknown dimension of another element that is, or has been, present in theimage stream. For example, the known dimension may be the distancebetween radiopaque (or otherwise visible) markers or segments of a tool.For some applications, the tool is a balloon, a marker wire, a stent, anendoluminal measurement catheter (such as an FFR catheter), and/or anendoluminal imaging catheter (such as an MRI, OCT, IVUS, NIRS, and/or anultrasound catheter).

For some applications, the known dimension is the length of analready-deployed stent, and/or the length of a radiopaque (or otherwisevisible) segment of a tool (e.g., a guide wire). Alternatively oradditionally, the known dimension is the diameter of a tool, such as aguiding catheter. For some applications, the diameter of the guidingcatheter is indicated by the user. Alternatively or additionally, thediameter of the guiding catheter is a default value set in the system orotherwise determined by the system.

For some applications, the guiding catheter is indicated by the user,via an input device (e.g., by pointing to the catheter using the inputdevice). Alternatively or additionally, the guiding catheter isidentified automatically by the system, by means of image processing.For some applications, the user indicates the image region in which theguiding catheter is located, and then the guiding catheter is detectedautomatically. For example, the user may indicate (using an inputdevice) a point anywhere in the region of the guiding catheter, and thenthe guiding catheter is detected automatically. Or, the user mayindicate a point on the guiding catheter itself for its identification.

Reference is now made to FIG. 11, which shows a fluoroscopic image inwhich a guiding catheter 30 has been segmented, in accordance with someapplications of the present invention. For some applications, after theguiding catheter is detected, it is segmented automatically so that theportion of its lumen that is within the image frame is highlighted.(Although the image in FIG. 11 is black-and-white, typically thesegmented catheter is highlighted in color.) For some applications, theguiding catheter is automatically detected and/or segmented usingtechniques similar to those described hereinabove for the automaticidentification of vessels.

For some applications, distance indicators are placed, in the form of agrid, in the entire image frame, in a region of interest within theimage frame, and/or in a segment of a vessel within the image frame.

For some applications, distance indicators are placed, in the form ofconcentric circles, in the entire image frame, in a region of interestwithin the image frame, and/or in a segment of a vessel within the imageframe. For some applications, distance indicators are placed in the formof concentric circles, the center of which circles is at the currentlocation of a cursor positioned by the user, or a location otherwiseindicated by the user.

For some applications, the distance indicators are used formeasurements, for example, quantitative vessel analysis (QVA)measurements, as described hereinbelow.

Displaying the Road Map and the Fluoroscopic Image Stream

For some applications, a road map (e.g., an automatically generated roadmap, as described hereinabove) is displayed in combination orconjunction with a stabilized image stream, for example, as described inWO 08/107905 to Iddan, which is incorporated herein by reference. Forexample, the road map may be overlaid upon a stabilized ornon-stabilized image stream, typically automatically. For someapplications, the road map is overlaid on a current image stream in realtime, or in near real time. Alternatively or additionally, the road mapis overlaid on an image stream, in reloop mode (i.e., a mode in which animage stream, which is typically a recent sequence, is replayed in aloop). For example, the road map may be overlaid on a fluoroscopic imagestream from which the road map was derived, while the fluoroscopic imagestream is being replayed in a loop.

Reference is now made to FIG. 12, which shows an automatically-generatedroad map, overlaid upon the angiogram from which it was generated, inaccordance with some applications of the present invention. For someapplications, overlaying of the road map on the angiogram from which itwas created is used to evaluate the accuracy and/or completeness of theroad map. As shown, the road map is typically marked as a set of thinboundary lines (although the road map may be marked in a differentmanner).

Reference is now made to FIG. 13, which shows an automatically-generatedroad map, overlaid upon an image frame belonging to a stabilized imagestream, in accordance with some applications of the present invention.As shown in FIG. 13, for some applications, the road map is overlaidupon a fluoroscopic image frame that is not an angiogram (that is, theroad map is overlaid on an image frame that was generated in the absenceof a contrast agent). As shown, the road map is marked as alighter-colored boundary line (although the road map may be marked in adifferent manner). Thus, the layout of the vasculature is depicted eventhough the vasculature itself is invisible in the underlyingfluoroscopic image. An inflated coronary balloon can be identified inthe fluoroscopic image by its two dark markers 34. Thus, the location ofthe balloon within the road map is determined.

For some applications, using the techniques described herein facilitatesfurther identification of the location of the balloon vis-à-vis thevessel in which it is placed, without requiring additional angiograms.Additional angiograms may necessitate irradiation of subject and/orstaff, and/or the additional injection of a potentially-damagingcontrast agent. Thus, by displaying the road map on top of thefluoroscopic image, irradiation of those involved in the procedure andthe total dosage of contrast agent administered to the subject may bereduced. Alternatively or additionally, there are other advantages todisplaying the road map on top of the fluoroscopic image.

Reference is now made to FIG. 14, which shows a road map 36 displayedside-by-side with a stabilized fluoroscopic image stream 38, edge linesof the road-map also being overlaid upon the fluoroscopic image stream,in accordance with some applications of the present invention. For someapplications, the road map is displayed side-by-side with thefluoroscopic image stream. In accordance with respective applications,the fluoroscopic image stream that is displayed next to the road map isthe native stream, a gated stream, an image tracked stream, and/or animage stream that is both gated and image tracked. For someapplications, a quantitative-vessel-analysis box 40 is displayed on thescreen. Quantitative vessel analysis measurements and/or diagrams aredisplayed in box 40 as described hereinbelow.

For some applications, image tracking of the fluoroscopic image streamis performed with respect to the guiding catheter or with respect to asegment thereof, as described hereinbelow. Alternatively oradditionally, image tracking is performed with respect to radiopaquemarkers or segments of a tool (e.g., a balloon, a stent, a valve, or adifferent tool), as described hereinbelow.

For some applications, the road map is generally displayed side-by-sidewith the fluoroscopic image stream, and from time to time is momentarilyoverlaid upon the fluoroscopic image stream. In accordance withrespective applications, the fluoroscopic image stream is native, gated,image tracked, and/or stabilized. For some applications, such overlayingis preceded by registration of the road map to fluoroscopic images.Typically, the road map is registered automatically, on-line, to thefluoroscopic images. Further typically, fiducials are identified withinthe road map and within the fluoroscopic image stream, in order tofacilitate the registration of the road map to the fluoroscopic imagestream. Fiducials are typically chosen that are observable even inimages of the fluoroscopic image stream that are generated in theabsence of a contrast agent. For example, the registration may beperformed by means of a portion(s) (e.g., a marker, or a radiopaqueportion) of a tool that is observable both in the road map and in thefluoroscopic images. For some applications, a road map corresponding toa given phase of the subject's cardiac cycle is generated, and isoverlaid on a fluoroscopic image stream that is gated with respect tothe same phase.

Reference is now made to FIG. 15 which shows a road map on which aregion of interest (ROI) has been marked. For some applications, theroad map that is displayed corresponds to a specific region of interest(ROI) within the angiogram(s) from which it was generated. For someapplications, the ROI is automatically set to be the central region ofthe angiogram. Alternatively or additionally, the ROI is indicated bythe user, such as by marking, using an input device, the center of theROI, or a window encompassing the ROI. Further alternatively oradditionally, the ROI is at first set automatically by the system andthen modified by the user. For some applications, the size of the ROIthat is displayed is pre-defined. For some applications, the zoom factorat which an image in the ROI is displayed may be changed by the user. Inaccordance with respective applications, the zoom factor at which a roadmap in the ROI is displayed is pre-defined, or may be changed by theuser.

For some applications, the road map is toggled between the full view(i.e., on the entire angiogram(s) from which it was generated) and thezoom-in view (i.e., only the ROI). Alternatively or additionally, theroad map switches automatically from the full view to the zoom-in viewonce a tool, such as a balloon, is identified by the system to haveentered the ROI in a corresponding fluoroscopic image. For someapplications, the balloon is identified as having entered the ROI basedupon the presence of a radiopaque (or otherwise visible) marker(s) orsegment, or some other identifiable portion, of the tool within the ROI.Similarly, for some applications, the road map switches automaticallyfrom the zoom-in view back to the full view once the aforementioned toolis identified by the system to have exited the ROI in a correspondingfluoroscopic image. For some applications, such switching, in eitherdirection, is performed by the user. For some applications, thetechniques described in the present paragraph are applied to the displayof the fluoroscopic image stream.

For some applications, leafing (i.e., browsing) back and forth amongmultiple angiograms is enabled. Typically, leafing is performed amongdifferent images belonging to the same angiographic sequence. Forexample, the user may wish to observe the gradual spread of contrastagent along multiple angiograms belonging to the same angiographicsequence.

For some applications, leafing is performed among selected angiogramsbelonging to different angiographic sequences. For example, whendetermining the placement of a stent by means of an angiogram prior toits deployment, the user may wish to observe an angiogram belonging to aprior sequence in which balloon pre-dilatation was performed at the samelesion in order to ensure that the stent is placed at substantially thesame location as the location at which pre-dilatation had beenperformed.

For some applications, the road map being displayed in conjunction withthe fluoroscopic image stream comprises an image of the contrast agentitself, for example, as described in WO 08/107905 to Iddan, which isincorporated herein by reference. For some applications, the road mapcomprises a synthesized background(s), enhancement(s), contour(s),pattern(s), texture(s), shade(s) and/or color(s) that was created basedupon the visual information acquired from the injection and/ordissipation of contrast agent, using computer graphics and/or imageprocessing techniques. Alternatively or additionally, the gray level ofthe road map is inversed, such that the road map appears light against adarkened background.

For some applications, the summation or combination of two road mapsgenerated at different times in the procedure is displayed, for example,as described in WO 08/107905 to Iddan, which is incorporated herein byreference. Typically, a road map generated during a given phase of afirst cardiac cycle is summed with a road map generated during a samephase of a second (typically immediately subsequent) cardiac cycle, tocreate a combined road map that displays more coronary vessels and/ordisplays coronary vessels with greater clarity. For some applications,such as in the case of a total or partial occlusion in a coronaryvessel, the combined road map may comprise the summation or combinationof a road map created from an injection of a contrast agent proximallyto the occlusion, and a second road map created from an injection of acontrast agent distally to the occlusion, such as via a collateralvessel and/or in a retrograde direction. For some applications, suchroad maps, which are based on the proximally- and distally-injectedcontrast agent, are created in the same phase of one or more cardiaccycles, which are not necessarily adjacent cardiac cycles.

For some applications, a three-dimensional road map is constructed bycombining two or more two-dimensional road maps recorded from viewingangles that are typically different by 30 degrees or more, for example,as described in WO 08/107905 to Iddan, which is incorporated herein byreference. For some applications, the two two-dimensional road maps(from which a three-dimensional road map is constructed) are recordedconcurrently from two different viewing angles, such as by means of abi-plane fluoroscopy system. Alternatively or additionally, athree-dimensional road map is created from CT angiography images,typically pre-procedural ones, and then correlated with the real timetwo-dimensional road map created from intra-procedural angiography.Further alternatively or additionally, a three-dimensional road map isconstructed from two or more different images taken from the sameviewing angle but during different phases in the cardiac cycle.

For some applications, the images displayed in conjunction with the roadmap and the stabilized image stream also comprise medical tools orprobes. For example, images (or contours) of such tools may be overlaidor projected upon or within the road map. Alternatively or additionally,the markers or radiopaque segments of such tools (or graphicalindications of such markers or segments) are overlaid or projected uponor within the road map. For some applications, the segment of the roadmap that is generally closer or closest to a designated tool ishighlighted or indicated in some graphical manner.

For some applications, the road map is corrected, typicallyautomatically, with respect to a designated vessel, based upon thelayout of a tool situated in that vessel. For example, the road map maybe corrected, typically automatically, with respect to a designatedvessel, based upon the detected location of markers or radiopaquesegments of a tool situated in that vessel. For some applications, ifthe tools (or markers or radiopaque segments thereof) are detected to beoutside of the road map, then the road map is redrawn or reshaped sothat such tools (or markers or radiopaque segments thereof) consequentlyappear to be within the road map.

For some applications, the medical tools or probes displayed inconjunction with the road map are activated or deployed insynchronization with a specific phase of a physiological signal orprocess, for example, as described in WO 08/107905 to Iddan, which isincorporated herein by reference. For some applications, the road map isdisplayed in conjunction with an image stream that is stabilized withrespect to that same phase.

For some applications, and in the case of images pertaining to acyclically-moving organ, different road maps are displayed, typically ina cyclical manner, in conjunction with the then-current phase of theorgan's motion cycle. For example, a dynamic road map as described maybe correlated to the cardiac cycle, and/or the respiratory cycle.

Performing Measurements

For some applications, measurements are performed, typicallyautomatically, based upon the determined boundaries of given vessels.For example, measurements may be performed based upon boundariesgenerated by means of the boundary generation techniques describedhereinabove for most or all vessels within an image. Or, measurementsmay be performed on a specific vessel or segment of a vessel, theboundaries of which have been generated in accordance with thetechniques described hereinabove.

Such measurements typically include lesion dimensions, reference arterydimensions, and quantitative vessel analysis (QVA), for estimating theextent of occlusion at a designated lesion. (QVA as used herein refersto the performance of the measurement techniques associated with atechnique that is known as quantitative coronary angiography (QCA), butincludes performing the measurement techniques (a) on any blood vesselof the subject, and not, specifically, a coronary artery, and (b) on anyimage of the blood vessel, and not, specifically, on an image of theblood vessel acquired using contrast agent. When performed with respectto coronary arteries, QVA is generally similar to QCA.)

For some applications, performing QVA using the techniques describedherein facilitates the performance of measurements without requiring amanual process of constructing the center line and deriving the vesseledges. Typically, QVA is performed automatically or almostautomatically, necessitating little to no user intervention orinteraction, by using the aforementioned techniques describedhereinabove for the automatic generation of center lines and edge lines.

For some applications, center lines and edge lines are validated bycross-referencing the lines, as described hereinabove. Subsequently,missing points/sections in edge lines are deduced and added, asdescribed hereinabove, to support the aforementioned automatic or nearlyautomatic QVA. For example, sets of edge points may be selected at bothsides of the gap, and a dynamic programming approach, optimizing apenalty function, is then applied to fill in the gap by proposingadditional edge points whose distances from the center line aretypically similar to those of the adjacent, already-known edge points.The process is typically applied continuously until the gap in the edgeline is bridged.

Reference is now made to FIGS. 16 and 19, which show, respectively, (a)a QVA box 48 which typically displays a QVA diagram with respect to asegment of a vessel that is part of a road map 44, and (b) a QVA diagram70, in accordance with some applications of the present invention. Asshown in FIG. 19, the horizontal axis of the QVA diagram represents thelongitudinal dimension of an occlusion, with distance indicators, whilethe vertical axis represents the extent (such as percentage relative tothe reference artery) of the occlusion. For some applications(typically, when a reference dimension, such as the diameter of theguiding catheter, has not yet been determined), the horizontal axis doesnot include distance indicators, but represents the longitudinaldimension of the occlusion. Typically, as shown in FIG. 16, and as shownon other figures which are described hereinbelow, the QVA diagram isdisplayed on the same screen as a road map, an angiogram, and/or afluoroscopic image of the vessel that is occluded. (Although it is shownas a box in FIG. 16, box 48 typically appears like one of the QVAdiagrams shown in FIGS. 18 and 19.)

For some applications, an ROI is indicated and then measurementsreferring to one or more vessels within the ROI are performed anddisplayed automatically. In accordance with respective applications, theROI is determined automatically (for example, by designating the centralarea of the image frame as the ROI), or is determined by the user. Forsome applications, road map 44 is displayed alongside a fluoroscopicimage stream 46, such as a live fluoroscopic image stream.

Reference is now made to FIG. 17A, which shows displayed on a screen (a)an angiogram 49, an ROI 50 having been identified in the angiogram, (b)an enlargement 51 of the ROI, in which a segment of a vessel (includingedges and ends 52) is marked, and (c) QVA measurements 54 of thesegment, in accordance with some applications of the present invention.For some applications, as an alternative, or in addition to, displayinga QVA diagram, QVA measurements are displayed, as shown in FIG. 17A.

Reference is also made to FIG. 17B, which shows displayed on a screen(a) an angiogram 55, an ROI 57 having been identified in the angiogram,(b) an enlarged roadmap 59 of the ROI, in which a segment 61 of a vesselis marked, and (c) a QVA box 63 of the segment, in accordance with someapplications of the present invention. (Although it is shown as a box inFIG. 17B, QVA box 63 typically appears like one of the QVA diagramsshown in FIGS. 18 and 19.)

For some applications, a user designates a single location in an imagethat is at or near a given location of a given blood vessel in theimage. For example, using an input device, the user may click at or nearthe given location. For some applications, in response to the userdesignating the single location, the system automatically detects alesion in the vicinity. For example, the system may identify edge linesand the reference diameters of the lesion. The reference diameters of alesion are typically the diameters of the vessel at the longitudinalextremities of the lesion (the longitudinal extremities also being knownas “healthy shoulders” to those skilled in the art). For someapplications, the reference diameters are the broadest location withinthe section of the blood vessel that is analyzed. In response todetecting the lesion, QVA is performed with respect to the lesion. Forsome applications, the lesion is graphically indicated, for example, byhighlighting or coloring the section of the vessel that is determined tobe the lesion.

For some applications, a lesion is automatically detected in accordancewith the following procedure. Scan lines are generated perpendicular tothe centerline of a segment of the vessel that is sampled. The image isresampled along the scan lines. Corresponding gray-level values arestored as columns of a rectangular matrix M, thereby resampling thesegment of the vessel as a straightened vessel segment. For thestraightened vessel segment, optimum upper and lower paths aredetermined (with respect to the middle row of M), which connect thefirst and last columns of M. The optimization criterion takes intoaccount the changes in gray-level along columns of M, and the paths'slopes. The vessel edge lines are obtained via back projection of upperand lower optimal paths on the original image.

A shortest path algorithm (such as that described by Dijkstra) is usedin order to avoid irregularities, such as small gaps and loops, in theedge lines. For some applications, the centerline is corrected basedupon the detected edge lines, and new scan lines are constructed. Foreach new scan line, vessel diameter is defined as a distance between thetwo points where the scan line intersects vessel boundaries.

For some applications, the technique described for the automaticidentification of a lesion is used to automatically identify a guidingcatheter. Typically, based on the known diameter (or another knowndimension) of the catheter, image units (i.e., pixels) are converted toabsolute units (e.g., millimeters or French units). Thus, for someapplications, measurements are provided in absolute units, such as,lesion length, the diameter of the vessel at each point along thecenterline, and/or minimum lumen diameter (which is also known as theMLD). For some applications, the level of occlusion (which is typicallyprovided as a percentage) at the minimum lumen diameter is determined bycomparing the diameter of the vessel at that point, to the diameter ofthe vessel at reference points of the vessel.

For some applications, in response to the user designating the singlelocation (as described hereinabove), edge detection and QVA areautomatically performed up until proximal and distal locations that areat suitable distances along the vessel in, respectively, proximal anddistal directions. For some applications, QVA is performed at distancesalong the vessel from the location that are equal in both proximal(i.e., typically upstream) and distal (i.e., typically downstream)directions along the vessel. Alternatively, the proximal distance isgreater than the distal distance. For example, in some cases it may beplanned for a stent to be deployed at a lesion within the blood vessel,such that the majority of the stent is deployed proximal of the centerof the lesion. Therefore, in response to the user designating the centerof the lesion, the QVA is performed up to a distance along the bloodvessel in the proximal direction that is greater than the distance alongthe blood vessel along which the QVA is performed in the distaldirection. Further alternatively, the proximal distance is less than thedistal distance (for example, in cases in which the center of a stent isto be deployed at a location that is distal with respect to the centerof a lesion).

For some applications, the maximum total distance along the blood vesselalong which QVA is performed typically automatically, is equal to thelength of the longest balloon or stent that is used with the system. Forsome applications, the total distance along the blood vessel along whichQVA is performed is equal to the length of the stent most likely to beused. In accordance with respective applications of the invention, suchdistances are preset, or are indicated by the user.

For some applications, the narrowest location within the region withrespect to which the QVA is performed is marked, and/or the minimallumen diameter at that location is indicated at that location. Asdescribed hereinabove, for some applications, the system automaticallydetects the reference diameters of a lesion. For some applications, thediameter of the lumen at the healthy shoulders is displayed. Asdescribed hereinabove, for some applications, the system automaticallyperforms QVA along a given distance along the vessel. For someapplications, the system automatically detects reference diameters of alesion within that distance, and (optionally) displays the diameter ofthe lumen at the healthy shoulders of the lesion. For some applications,the level of occlusion of the blood vessel at the minimum lumen diameteris determined by comparing the minimum lumen diameter to the referencediameters, for example, by comparing the minimum lumen diameter to anaverage of the two reference diameters.

For some applications, the user moves a cursor (i.e., a manuallycontrolled indicator on a computer screen) along (i.e., through, on,beside, over, or parallel to the length or direction of) the designatedvessel in the image, and interactively receives an indication of thevessel's diameter at the current location of the cursor. Alternativelyor additionally, the user receives an indication of the minimum lumendiameter, or of reference diameters of a lesion in the vicinity of thecurrent location of the cursor. For some applications, the level ofocclusion of the blood vessel at the minimum lumen diameter isdetermined by comparing the minimum lumen diameter to the referencediameters, for example, by comparing the minimum lumen diameter to anaverage of the two reference diameters.

For some applications, the user designates a first location with thecursor. Subsequently, the user moves the cursor along the blood vesseland receives an indication of the average diameter, the minimumdiameter, and/or another quantitative measure of the blood vesselbetween the first location and the current location of the cursor.Alternatively or additionally, the user moves a cursor along thedesignated vessel and interactively receives an indication of thelongitudinal distance between the current location of the cursor and thefirst location, the proximal end, and/or the distal end, of the vessel.Further alternatively or additionally, the user receives an indicationof the minimum lumen diameter, or of reference diameters of a lesion inthe vicinity of the current location of the cursor. For someapplications, the level of occlusion of the blood vessel at the minimumlumen diameter is determined by comparing the minimum lumen diameter tothe reference diameters, for example, by comparing the minimum lumendiameter to an average of the two reference diameters.

For some applications, the user moves a cursor along the designatedvessel and interactively receives an indication of the longitudinaldistance between the current location of the cursor and the proximallocation of the vessel described hereinabove. Alternatively oradditionally, the user moves a cursor along the designated vessel andinteractively receives an indication of the longitudinal distancebetween the current location of the cursor and the distal location ofthe vessel described hereinabove. Typically, the aforementionedlongitudinal distances are calculated along the vessel's center line.Further typically, the distances are determined based upon some knownanatomical feature, or based upon a known dimension of another elementthat is, or has been, present in the image stream, as describedhereinabove.

For some applications, the interactive QVA techniques described in theprevious paragraph are used to replace virtual stenting. For example,instead of determining which stent should be placed at a lesion bygraphically generating a virtual stent at the lesion, QVA is performedwith respect to the lesion. Based upon the QVA, it is determined whichstent should be placed at the lesion, and/or specific dimensions of astent that should be placed at the lesion.

For some applications, as the user moves the cursor over the vessel, theportion of the vessel over which the cursor has moved is graphicallyindicated, for example, by highlighting or coloring the section of thevessel over which the cursor has moved. For some applications, in thismanner, the user generates a graphical indication of a lesion. For someapplications, such graphical indication of the lesion is used to replacevirtual stenting.

For some applications, in response to an input from the user, theprocessor only allows movement of the cursor on the screen along (i.e.,through, on, beside, over, or parallel to the length or direction of)paths of the blood vessels. For example, the cursor may be allowed tomove along center lines, or other lines within the blood vessels. Or,the cursor may be allowed to move alongside the blood vessels but in adirection that is parallel to paths (for example, center lines) of theblood vessels.

Reference is now made to FIG. 18, which shows QVA diameter diagrams 66and 68, in accordance with some applications of the present invention.As described hereinabove, for some applications, an ROI 62 is identified(for example, an ROI in an angiogram 65 is identified, as shown in FIG.18). For some applications, a user identifies and designates thelocation of the center of a lesion 64, for example, by clicking on thecenter of the lesion in the angiographic image, or in the enlarged imageof the ROI. For some applications, QVA diagram 68 of the lesion isgenerated, in which both edges of the vessel are illustrated at theiroriginal shape in the form of a diameter diagram. In diagram 68, thevessel's edges are aligned and depicted along and at both sides of thevessel's straightened center line, such that the center line serves asthe horizontal axis of the diagram. Alternatively or additionally, QVAdiagram 66 is generated. QVA diagram 66 is a graph which plots thediameter, or the level (e.g., percentage) of occlusion of the bloodvessel (on the y-axis) against the longitudinal distance along the bloodvessel on the x-axis. Thus, using diagram 66, the cumulative narrowingat any given point along the vessel may be observed. For someapplications, generating diagram 66 facilitates identification of thenarrowest location within the occlusion and the extent of narrowing atthat location.

For some applications, a sequence of endoluminal cross-sectional imagesis generated by an endoluminal imaging catheter. Respectivecross-sectional images of the blood vessel are assigned as correspondingto regions of an extraluminal image of the blood vessel (for example, byregistering the endoluminal images to the extraluminal image). QVAdiagrams or measurements are generated for regions of the extraluminalimage. Respective cross-sectional images of the blood vessel aredisplayed together with (e.g., alongside) the corresponding QVA diagramand/or measurements. For some applications, the endoluminal images (withor without the corresponding QVA diagrams and/or measurements) aredisplayed as stacked and aligned along a straightened center line of theblood vessel. For some applications, the endoluminal images aregenerated by the imaging catheter during its pullback. In accordancewith respective applications, the endoluminal imaging catheter may be,for example, an IVUS catheter, an OCT catheter, a NIRS catheter, an MRIcatheter, or any combination thereof.

For some applications, QVA is performed in response to the user clickingat or near two locations along a vessel, the locations indicating theproximal and distal edges of the lesion. For some applications, agraphical window appears on the screen, and the two locations aredesignated based on how the user positions the edges of the windowand/or sizes the window, with respect to the designated vessel. For someapplications, the size of the window changes automatically until theuser clicks to indicate that the then-current size is to be selected.

Reference is now made to FIG. 19, which shows a QVA diagram 70comprising a representation of a tool at its relative location withinthe lesion on which QVA has been performed, in accordance with someapplications of the present invention. For some applications, when atool such as a balloon and/or stent is present at the occlusion at thetime a QVA diagram is generated, a representation of the tool, or ofradiopaque markers or segments thereof, is incorporated into the QVAdiagram with the position of the tool indicated relative to theocclusion, as shown. Typically, the tool representation is displayedwithin the lesion on the QVA diagram, at a location that corresponds tothe actual location of the tool within the lesion. For someapplications, the location of the tool relative to the lesion isdetermined automatically. For some applications, QVA is performedautomatically, upon the identification of the aforementioned radiopaquemarkers or radiopaque segments within a vessel. For example, QVA may beperformed on a segment of the vessel between the two markers, or along apre-defined distance along the vessel from a site that is a givendistance beyond one of the markers, or between two sites that are atrespective given distances beyond respective markers.

For some applications, the distance indicators in a road map describedhereinabove are used for measurements (e.g., automatic measurements).For example, measurements may be performed of (a) the dimensions of anartery, such as the length and/or diameter of the artery, and or (b) thedimensions of a lesion, such as the length and/or diameter of thelesion. For some applications, the diameter of a reference point of theartery (or of a different artery), at one or both sides of an occlusion,is measured. In accordance with respective applications, the referencepoint of the artery is indicated by the user, or is identified,typically automatically, by means of image processing due to its largerdiameter relatively to that of the occlusion. For some applications, thereference point of the artery is assumed by the system to be at a setdistance from the center of the occlusion, or at a set distance from thecenter of an ROI.

Reference is now made to FIG. 20, which shows a road map upon which aredisplayed measurements 72 of the diameter of reference points of anartery on both sides of an occlusion, in accordance with someapplications of the present invention.

For some applications, the measurements are used in the selection of amedical tool (e.g., a balloon, and/or a stent) to be deployed at theocclusion.

Image Tracking and Tool Positioning

For some applications, a virtual tool is positioned upon the road map,and/or upon the stabilized images. Typically, the positioning of avirtual tool is an intermediate step leading to the selection andpositioning of a corresponding actual tool. For some applications,techniques for the generation and positioning of a virtual tooldescribed in WO 08/107905 to Iddan, which is incorporated herein byreference, are used in combination with techniques described herein.

For some applications, image tracking is applied to a stream of imageframes to facilitate the positioning of a tool, deployment of a tool,the deployment of an already-deployed tool (such as by post-dilatationof a balloon within an already-deployed stent), post-deployment analysisof a deployed tool, general observations, or any combination thereof.

For some applications, image tracking is performed with respect to aradiopaque (or otherwise visible) segment or marker(s) of the tool,which is/are visible in most or all image frames and are identifiedautomatically by means of image processing. The tool is aligned in imageframes of the image stream, based on the identified markers or segmentof the tool. For example, the image frames may be aligned such thatmarkers in at least most of the image frames are aligned. The alignedimage frames are displayed as an image stream. For some applications,image frames are tracked in the aforementioned manner, but with respectto a portion of the subject's anatomy, for example, vascularcalcification of the subject.

For some applications, the tool with respect to which image frames aretracked is a balloon, a marker wire, a guide wire, a stent, anendoluminal imaging catheter (e.g., a catheter that uses an imagingmodality that is MRI, OCT, IVUS, NIRS, ultrasound, or any combinationthereof), and/or an endoluminal measurement catheter (e.g., an FFRcatheter).

The identification of the markers or radiopaque segments is typicallyperformed automatically by the system. For some applications, theidentification is performed within one or more entire image frames.Alternatively, the identification is performed within an ROI which waspreviously set by the system and/or the user. Further alternatively, theROI is automatically set by the system to include regions in which themarkers are more likely to appear, and to exclude regions in which themarkers are less likely to appear. For some applications, the ROI isindicated graphically, overlaid upon the image stream.

For some applications, markers are identified by the user designating aregion within the image in which the markers are more likely to appear,followed by the system automatically identifying the markers within thatregion. For some applications, the user is subsequently prompted toconfirm the identification selection of markers by the system. Inaccordance with respective applications, the region is designated by theuser within a dynamic image stream, or within a static image frame takenfrom within the image stream. Alternatively, the user clicks on (orotherwise indicates) the device or the vicinity of the device, and, inresponse, the image tracking with respect to the device markers orsegments commences.

Once the markers have been identified in one or more image frames, thenthe system typically continues to identify (i.e., detect) those markersautomatically in the subsequent image frames along the image stream or asegment thereof, and displays a tracked image stream. Typically, inorder to detect the markers, the system accounts for phenomena such asthe following:

(1) In some image frames, contrast agent may hide, or partially hide themarkers. Typically, if the markers are not visible due to the contrastagent in a given frame, then that frame is skipped and is not used inthe image-tracked image stream. For some applications, the systemidentifies markers in image frames in which the markers are partiallyhidden by the contrast agent, and the image frames are used in theimage-tracked image stream.

(2) A fluoroscopic image is typically a two-dimensional projection ofthe three-dimensional portion of the subject's body that is beingimaged. This may result in darkened regions, which appear similar tomarkers, but which are not markers. For example, regions of the image inwhich vessels (particularly vessels that contain contrast agent) areprojected onto the two-dimensional image such that they appear to becrossing each other, may appear as a dark circle. Similarly, regions inwhich a tool crosses a vessel, two tools cross each other, a toolcrosses the edge of a rib, or a vessel crosses the edge of a rib, mayappear similar to a marker. Examples of such tools include a wire (suchas a CABG wire, or a guide wire), a CABG clip, an electrode, a lead,and/or a catheter lumen.

(3) In a dynamic image stream, markers may be blurred due to the rapidmovement of blood vessels.

For some applications, image frames in which the markers are notidentified are automatically skipped. For some applications, blending isperformed among tracked image frames which may further stabilize thetracked image frames. When image frames of the original image stream areskipped (e.g., due to non-identification of a marker), then thetransition between the adjacent image frames to the skipped image frameis typically performed with blending.

For some applications, a mask is applied to the tracked image streamsuch that the areas more remote from the tracked markers, whichtypically have greater motion in the tracked image stream, are blurred,hidden, or partially hidden. Such a masked image stream may be easierfor a user to observe, because of the reduction in distractions in thetracked image stream. Alternatively or additionally, the periphery ofthe image (e.g., the anatomy outside the vascular system) is blurred,hidden, or partially hidden.

For some applications, the automatic identification of markers comprisessome or all of the following phases, which are typically performed inreal time:

-   -   a. Pre-processing: Individual image frames (or an ROI within        such frames) along the image sequence are pre-processed in order        to facilitate the subsequent identification of markers. Such        pre-processing typically comprises the reduction of static        and/or dynamic noise, background removal, or a combination        thereof. For some applications, a median filter, a Mexican hat        filter, a directional Mexican hat filter, and/or a low-pass        filter is applied to the individual image frames. For some        applications, the preprocessing includes the detection and        removal from the image frames of CABG wires, wires and/or        electrodes of implanted tools such as pacemakers or        defibrillators, and/or wires and/or electrodes of external        devices such as an ECG monitor, and/or an external        defibrillator.    -   b. Filtering of non-marker-like features: Individual image        frames (or an ROI within such frames) along the image sequence        are processed to filter out remaining features that are clearly        not markers. For some applications, the filtering includes the        application to the image frames of a median filter, a Mexican        hat filter, a directional Mexican hat filter, a maximal stable        external regions (MSER) filter, an MSER-like filter, a Hessian        filter, or a combination thereof.        -   For some applications, Hessian eigenvalues are calculated            for each pixel in each image frame, or for all pixels within            an ROI of the image frame. Typically, local clusters of            pixels with high minimal eigenvalues represent a            “paraboloid-like” area in the image and are identified as a            potential radiopaque marker.    -   c. Scoring: Remaining features in individual image frames (or an        ROI within such frames) along the image sequence are assigned a        “fitness” score (i.e., a “markerness” score, or a “dotness”        score in the case of the most common markers), describing the        likelihood that they are markers. For some applications, the        score is calculated from the abovementioned filtering.    -   d. Matching: Remaining features in individual image frames (or        an ROI within such frames) are analyzed for matching with one        another. For example, in the case of aiming to detect the two        radiopaque markers of a coronary balloon, pair matching is        performed. Such matching is typically performed based upon        relative location, distance, orientation, visual similarity,        and/or other factors.    -   e. Detection: For some applications, once a pair of clusters        (with such two clusters being strong candidates to be tool        markers) has been identified at a similar distance from one        another and/or relative angle to one another in several        consecutive image frames, the pair of clusters is determined to        be the two markers of a tool.    -   f. Tracking: Typically, image tracking, as described hereinabove        is performed with respect to the two markers for the purposes of        image stabilization and/or enhancement.

It should be noted that while using a pair of radiopaque markers as aprimary example, the techniques disclosed above (or a derivationthereof) may be applied to other radiopaque (or otherwise visible)segment(s) or marker(s) or feature(s) of a tool, or feature(s) of theanatomy, which are visible in most or all image frames.

For some applications, for the purpose of image tracking, the identifiedsegment or marker(s) of the tool is aligned automatically in most, orall, image frames such that it remains at a similar or same relativeposition throughout the image stream. Further typically, this results inthe tool being aligned automatically in most, or all, image frames suchthat it remains at a similar or same relative position throughout theimage stream.

For some applications, a virtual line that connects the markers isaligned such that it remains at the same or a similar relative positionthroughout the image stream. For example, the alignment may includetranslating individual image frames such that the markers (or thevirtual line connecting the markers) remain at a same or similarlocation within the image frames throughout the tracked image stream.Alternatively or additionally, the alignment includes rotatingindividual image frames such that the angle of the virtual lineconnecting the markers is same or similar throughout the tracked imagestream. Further alternatively or additionally, the alignment includesscaling of individual image frames such that the distance between themarkers is the same throughout the tracked image stream. For someapplications, the alignment is performed with respect to a virtualfeature calculated from the individual locations of the markers. Forexample, the virtual feature may be an average between the locations ofthe individual markers, or a weighted average of the locations of theindividual markers.

For some applications, image tracking on markers, or on a virtualfeature derived from the markers, continues for as long as certainparameters pertaining to such markers are observed at similar values inat least most of the image frames (or in a ROI within such frames). Forexample, the parameters may include the markers' location, distance fromone another, angle relative to one another, linear velocity betweenconsecutive frames, angular velocity between consecutive frames, sizes,“markerness” score, x-ray intensity, surrounding intensity gradients, orany combination thereof.

Typically, the aforementioned image tracking results in the tool beingdisplayed as relatively stable, while the surrounding anatomy isdisplayed as moving relative to the generally-stable tool in the courseof the organ's motion cycle.

For some applications, visibility of image elements surrounding the toolis reduced in the displayed, tracked image stream, in order to reducevisual distractions. Typically, such reduction in visibility facilitatesobservation of the tool and the vicinity of the tool within the trackedimage stream. For some applications, the reduction in visibility isachieved by applying a mask to the images, such that the visibility ofregions of the displayed tracked images that are relatively remote fromthe tool is reduced. For some applications, the visibility of the imageelements is reduced gradually, such that there is a typically inverserelationship between the distance of an image element from the tool andthe visibility of such image element in the displayed, tracked images.

For some applications, in the region of the tool, pixels are displayedthat are not averaged. Pixels that are distant from the tool areaveraged with pixels from other image frames that are in a correspondinglocation to those pixels, for example, as described hereinbelow. Forsome applications, there is a direct relationship between the extent towhich pixels are averaged, and the distance of the pixels from the tool.

Image tracking with respect to a portion of the tool typically effects avisual separation between two elements of the motion of the toolpositioned within a vessel attached to the heart. The motion of the tooltogether with the vessel is typically hidden, while the motion of thetool relative to the vessel typically remains visible. For someapplications, such separation of motion elements typically facilitatesthe ability of the user to determine the extent of the motion of thetool relative to the vessel (e.g., cyclic longitudinal motion within theblood vessel) in the course of the heart's motion cycle. That, in turn,typically enables the user to determine the importance of deploying thetool at a specific phase in the motion cycle, and if so, at whichspecific phase, and location.

For example, when placing a balloon (or a balloon carrying a stent)relative to a designated lesion within a coronary artery, image trackingis performed on the radiopaque marker(s) of the balloon. Consequently,the motion of the balloon together with the artery, in the course of theheart's motion cycle, is typically hidden. At the same time, the motionof the balloon relative to the artery, in the course of the heart'smotion cycle, typically remains visible. Consequently, the user canobserve (typically while being demonstrated by contrast agent) thelocation of the balloon prior to its inflation, and/or the stent priorto its deployment, at a systolic or end-systolic phase versus adiastolic or end-diastolic phase. Based on the observed locations of theballoon or the stent, deployment of the balloon or the stent at adesired location is timed to the phase in the cardiac cycle at which thepre-deployment position is at the desired location.

In accordance with respective applications, the user observes theballoon in the described manner, in real time, in near real time, or inreloop mode.

For some applications, the extent of the motion of the balloon relativeto the artery is quantified automatically. For example, the location ofthe tool's markers or radiopaque segments relative to a known anatomicalfeature (such as an occlusion, a bifurcation, an ostium) isautomatically determined over the course of a cardiac cycle.

For some applications, image tracking is performed with respect to theradiopaque segment(s) of a tool configured to penetrate an occlusion.The inventors hypothesize that such image tracking facilitatesdetermination by a user of the orientation of the tool relative to thevessel at any given moment, and thus assists the operator in determiningwhen to push forward and/or activate the tool.

For some applications, identification of the end-diastolic andend-systolic points within a cardiac cycle is determined from an ECGsignal, and/or by means of image processing. For example, such means ofimage processing may include the identification of a reversal of thedirection in which a tool's radiopaque segment(s) moves.

For some applications, the possibly-varying location of the toolvis-à-vis the vessel in the course of the heart's motion cycle isfurther highlighted by graphical means. For example, portions (such asthe radiopaque segment(s) or marker(s)) of the tool may be presented indifferent colors, shapes, textures and/or sizes at a systolic orend-systolic phase versus a diastolic or end-diastolic phase.Alternatively or additionally, other elements in the image frames changetheir appearance according to the phase in the motion cycle. Furtheralternatively or additionally, sounds are used to denote a selectedphase in the motion cycle.

Reference is now made to FIG. 21, which shows markers 74 of a balloonwithin a vessel in an angiogram. For some applications, the markers areartificially colored a first color in one phase of the cardiac cycle(e.g., the end-systolic phase), and are colored a different color in adifferent phase of the cardiac cycle (e.g., the end-diastolic phase).

Reference is also made to FIG. 22, which shows images 78 and 80 ofmarkers of a balloon situated within a coronary artery, at respectivephases of the subject's cardiac cycle. Arrow 76 in each of the figuresdenotes the distance of the upper marker from the beginning of anocclusion of the coronary artery. It may be observed that thepre-deployment position of the marker relative to the artery issubstantially different at different phases of the cardiac cycle,indicating to the inventors that proper deployment at a desired locationshould to be timed to the phase in the cardiac cycle at which thepre-deployment position is at the desired location.

For some applications, techniques are provided for facilitating thedetermination of the location of a tool, such as a balloon or a ballooncarrying a stent, with respect to an artery, during image sequences forwhich a contrast agent has not been administered to the subject. Forsome applications, the current locations of radiopaque markers orradiopaque segments of the tool are determined with respect to a roadmap that was generated from a previously-acquired angiogram. Typically,the procedure includes some or all of the following phases, and istypically performed in real time:

-   -   a. A road map is generated, typically automatically, for        example, according to techniques described hereinabove.        Typically, the road map is updated automatically during the        procedure, in response to the system detecting that a new        angiographic sequence has commenced, as described hereinabove.        For some applications, commencement of the new angiographic        sequence is detected even when the angiographic sequence is        performed under fluoro mode. For some applications, the shape of        a vessel through which tools are inserted changes in the course        of the procedure due to occlusions being reduced, the tool        itself straightening the artery, and/or other reasons, and the        road map is updated in order to account for these changes.    -   b. Features residing within the vessel at a relatively fixed        location are identified, such features being observable even in        images generated in the absence of contrast agent. Such features        may include a distal portion of the guiding catheter through        which the tool is inserted, a radiopaque portion of the guide        wire upon which the tool is inserted, and/or other features. For        some applications, the identification of such features is        automatic, or semi-automatic (i.e., requiring some user        interaction but less than would be required without using the        techniques described herein), for example, in accordance with        techniques described hereinabove. For some applications, the        entire length of the guide wire (or of the catheter carrying the        tool) is identified, for example using techniques similar to the        ones described hereinabove for the automatic identification of        center lines.    -   c. A current image stream of the tool inside the blood vessel is        generated. The markers or radiopaque segments of the tool that        is currently inserted into the blood vessel are identified in        the image stream, typically automatically and typically in real        time, according to techniques described hereinabove. The markers        or radiopaque segments are identified even in current images        generated in the absence of contrast agent (and in which the        artery itself is not visible). The location of the markers with        respect to the observable features is determined based upon the        current image stream.    -   d. The tool markers or radiopaque segments are projected,        typically automatically and typically in real time, upon the        previously-generated road map. Typically, the current location        for marker projection within the road map is calculated relative        to the aforementioned observable features described in step b.        For example, the current distance(s) of the markers from the        observable feature(s) (as determined in step c) may be applied        along the applicable vessel in the road map in order to        determine the location on the road map at which the markers will        be projected. For some applications, the angiogram from which        the road map is generated is gated to a specific phase in the        cardiac cycle (e.g., the end-diastolic phase), and the location        of the markers with respect to the observable features is        determined in a current image frame that is also gated to that        phase.        -   In an alternative application, the road map is projected            (continuously or in a gated manner) upon the image stream            that contains the markers or radiopaque segments (as opposed            to the image stream being projected upon the road map).

Synchronized Tool Deployment

For some applications, once the location of the tool is suspected to orhas been determined to vary in the course of the organ's motion cycle,actuation of the tool is synchronized to a selected phase in the motioncycle of the organ. For some applications, the synchronized actuation ofthe tool is performed in accordance with techniques described in WO08/107905 to Iddan, which is incorporated herein by reference.

For example, when inflating a balloon (or, for example, a ballooncarrying a stent) relative to a designated lesion within a coronaryartery, and if the pre-deployment position of the balloon relative tothe artery varies considerably over the course of the heart's motioncycle, then the user may place the balloon such that its locationrelative to the lesion is correct at a specific phase of the cardiaccycle, and then inflate the balloon in synchronization to that phase.For some applications, such synchronized inflation is performed by meansof apparatus for facilitating synchronized inflation described in WO08/107905 to Iddan, which is incorporated herein by reference.

For some applications, inflation is synchronized specifically to aselected phase in the subject's ECG signal. The ECG signal is typicallyreceived from an ECG monitor, or from a cardiac rhythm management (CRM)device, such as a pacer, or a defibrillator. For some applications, theprocessor identifies the selected phase of the ECG signal.Alternatively, the selected phase (e.g., the R wave of the ECG signal)is identified by the ECG monitor. Further alternatively, the selectedphase (e.g., the R wave of the ECG signal) is identified by the CRMdevice.

For some applications, the aforementioned synchronization (and/or thesynchronization of the actuation, deployment, and/or movement of othertools described herein) accounts for the delay in the generation of theECG signal by the ECG monitor. For example, the delay may be determinedin the following manner: A cardiac signal is generated by an electronicpatient simulator. That signal is then fed as an input signal to the ECGmonitor. The time difference between that input signal and thecorresponding ECG signal produced by the ECG monitor is measured with anoscilloscope. If the delay D1 is measured in milliseconds and the heartrate (HR) is measured in beats per second, then, in order to actuate thetool in synchronization with a given phase of the ECG signal (e.g., theR-wave), a signal to actuate the tool is applied ((1000/HR)−D1)milliseconds after the given phase of the ECG cycle is detected.

For some applications, the value of HR as applied to the aforementionedsynchronization is set according to the subject's most current heartrate. Alternatively, the value of HR is set according to the subject'saverage heart rate along a selected number of most recent cardiaccycles.

Reference is now made to FIG. 23A, which shows an image of a balloonbeing inflated inside a stent. In FIG. 23A, edge lines have been addedmanually to the balloon, although, in accordance with some applicationsof the present invention, edge lines are added automatically. In thecourse of the deployment of certain tools within a vessel, a balloon isinflated within the tool, in order to expand the tool such that the toolcomes into contact with an inner surface of the vessel. For example, aballoon may be inflated inside a stent such that the stent is broughtinto contact with an arterial wall. Alternatively, a balloon may beinflated inside a prosthetic valve, in order to deploy the valveadjacent to the remains of a natural valve. Further alternatively, aballoon may be inflated inside a graft, in order to deploy the graft.

Typically, the tool is shorter than the balloon, therefore, the balloonhas overhanging portions at each end of the balloon. In such cases, oneor both of the overhanging portions of the balloon typically initiallyexpands before the remainder of the balloon expands. The overhangingportion becomes attached to the inner surface of the vessel, and, atthat point, the longitudinal position of the balloon (and the tool)relative to the vessel typically becomes fixed, such that there is nolongitudinal motion of the balloon relative the vessel. Subsequently,inflation pressure is further raised so that the tool itself attaches tothe inner surface of the vessel.

For some applications, synchronization is applied such that theinflation is performed in a stepwise manner, in phase with a selectedphase of the cardiac cycle, throughout the entire inflation procedure.Alternatively, synchronization is applied only during certain segment(s)of the inflation process, while inflation during earlier or latersegment(s) of the process remains continuous.

For some applications, when deploying a tool (e.g., a stent) using theballoon, synchronization is applied in one or more steps to theinflation of one or more of the overhanging portions of the balloon,until the overhanging portion has become attached to the inner surfaceof the vessel and the longitudinal position of the balloon relative tothe vessel has been fixed. Subsequently, the remainder of the inflationprocess, is continuous (and typically not synchronized) until the stentitself has become attached to the inner surface of the blood vessel.

Alternatively, inflation of the balloon is at first continuous untilsufficient pressure has been applied to unfold the balloon.Subsequently, synchronization is applied in one or more steps to theinflation of one or more of the overhanging portions of the balloon,until the overhanging portion has become attached to the endoluminalwall and the longitudinal position of the balloon relative to the vesselhas been fixed. Subsequently thereto, the remainder of the inflationprocess is continuous (and not synchronized) until the stent itself hasbecome attached to the inner surface of the blood vessel.

For some applications, timing of the aforementioned one or moresynchronized steps, relative to the detected desired phase in thevessel's motion cycle, takes into account parameters which affect thetime delay D2 milliseconds between the activation of an inflation stepby the aforementioned device for facilitating synchronized inflation andthe corresponding increase in the diameter of the balloon and/or stentbeing inflated. For some applications, parameters that affect D2 includecatheter parameters (e.g., length, inner diameter), balloon and tool(e.g., stent) parameters (e.g., length, diameter, nominal pressure),inflation fluid parameters (e.g., viscosity, relative portions of salineand contrast agent), or any combination thereof.

Typically, an additional parameter which affects the aforementioned timedelay D2 is the amount of air trapped within the catheter carrying theballoon and/or stent. For some applications, activation of the apparatusfor facilitating synchronized inflation is preceded by suction oftrapped air out of the catheter. For example, such suction may beperformed manually by the operator, such as by means of a syringeconnected to the proximal end of the catheter. Alternatively, thesuction may be performed by an electromechanical apparatus. For someapplications, the electromechanical apparatus is coupled with theapparatus facilitating synchronized inflation.

For some applications, delay D2 is measured in milliseconds, and theheart rate is measured in beats per second. In such cases, subsequent todetecting the desired phase of the subject's ECG (or other) signal, theactuation signal for actuating the tool is generated after((1000/HR)−D2) milliseconds.

For some applications, in order to account for the aforementionedECG-related delay D1 and inflation-related delay D2, and where the heartrate is calculated as HR beats per second, the actuation signal isdelayed by ((1000/HR)−D1−D2) milliseconds, after detecting the desiredphase of the subject's ECG signal.

For some applications, synchronization is applied to the deployment of astent that is not balloon-inflatable but rather is self-expanding. Forsome applications, a delay of D3 milliseconds between the activation ofthe self-expansion mechanism and the stent actually expanding to thelumen's internal diameter is determined by means of ex-vivoexperimentation with the stent. Alternatively or additionally, D3 isdetermined by means of performing measurements, under intra-proceduralimaging, of in-vivo stent deployments.

For some applications, delay D3 is measured in milliseconds, and theheart rate is measured in beats per second. In such cases, subsequent todetecting the desired phase of the subject's ECG (or other) signal, theactuation signal for actuating the tool is generated after((1000/HR)−D3) milliseconds.

For some applications, when accounting for the aforementionedECG-related delay D1 and expansion-related delay D3, and where the heartrate is calculated as HR beats per second, the actuation signal isgenerated ((1000/HR)−D1−D3) milliseconds, after detecting the desiredphase of the subject's ECG signal.

In further applications, the aforementioned synchronization is appliedto the gated (for example, stepwise) motion and/or activation of a toolused for penetrating an occlusion within the vessel, and/or to adifferent tool.

Reference is now made to FIGS. 23B and 23C, which are schematicillustrations of apparatus for use with an inflation device 82,including a reusable portion 84, and a single-use portion 86, inaccordance with some applications of the present invention. The reusableportion may be coupled and decoupled with respect to the single-useportion, as shown, respectively, in FIG. 23B and FIG. 23C. As describedin WO 08/107905 to Iddan, which is incorporated herein by reference,some portions of the apparatus for facilitating a synchronized inflationof a balloon and/or stent may be reusable, while other portions may beintended for single use. For some applications, the reusable portionsare ones which do not come in contact, during the inflation process,with the inflation substance (such as a fluid), and the portionsintended for single use are ones which come in contact, during theinflation process, with the inflation substance (such as a fluid).Alternatively or additionally, the reusable portions are ones which donot come in contact, during the inflation process, with the tool beinginflated (such as a catheter carrying a balloon, a stent, and/or avalve), and the portions intended for single use are ones which come incontact, during the inflation process, with the tool being inflated(such as a catheter carrying a balloon, a stent, and/or a valve).

Enhancement of an Image

For some applications, the image of the tool within the stabilized imagestream is enhanced in real time or near real time. For some applicationsenhancement of the image of the tool is performed in combination withthe techniques described in WO 08/107905 to Iddan, which is incorporatedherein by reference.

For some applications, enhancement is performed automatically uponframes that have been image-tracked such that the tool is displayed in asame or similar relative location throughout most or all frames, asdescribed hereinabove. For some applications, enhancement is performedby means of temporal filtering of the image-tracked frames. Typically,enhancement is performed in real time, or in near real time.

For some applications, the temporal filtering applies a weightedaveraging function to the value of each pixel, as defined by itsrelative locations in a series of consecutive frames, and displays theresulting image. Alternatively or additionally, the temporal filteringapplies a median function to the value of each pixel, as defined by itsrelative locations in a series of consecutive frames, and displays theresulting image. Further alternatively or additionally, the temporalfiltering applies a mode function to the value of each pixel, as definedby its relative locations in a series of consecutive frames, anddisplays the resulting image.

For some applications, in addition to the application of a temporalfilter, a spatial filter is applied to increase the contrast in theenhanced image. For example, the spatial filter may be a levelingfilter. For some applications, contrast is increased by histogramstretching, and/or by gamma correction.

In accordance with respective applications, contrast enhancement isspecifically applied to the edges of a tool, such as a balloon, or tothe struts of a tool, such as a stent.

For some applications, only the final image, representing the outcome ofthe enhancement process, is displayed. Alternatively, intermediateframes, reflecting gradual enhancement, are also displayed on-line.

For some applications, enhancement is performed upon a number oftypically-consecutive gated image frames. When using gated images, theenhancement is typically applied to fewer image frames than when theenhancement is applied to non-gated image frames, which may degrade theoutcome of the enhancement process. However, such gated frames are oftenalready aligned to a substantial extent, which may improve the outcomeof the enhancement process.

For some applications, the enhancement is performed with respect to animage of an anatomical structure. For example, the anatomical structuremay be a valve or a portion thereof, and/or a section of a vessel. Forsome applications, the structure is a lesion, which is typicallyvisualized during contrast injection. For some applications, the lesionis identified by the user, for example, as part of the automated QVAprocess described hereinabove. For some applications, enhancement isapplied, in particular, to the edges of the structure, which are madevisible by means of contrast agent, or which are visible even withoutcontrast agent due to a physiological phenomenon. For example,calcification is typically visible even without contrast agent.

For some applications, enhancement is performed utilizing onlystabilized (e.g., image tracked, and/or gated) image frames.Alternatively, the enhancement utilizes non-stabilized image frames. Forexample, in the case of a calcified anatomical structure, such structureis typically more rigid than its environment and therefore motion duringthe cardiac cycle is typically reduced. Therefore, for someapplications, non-stabilized images of the calcified structure are usedfor the enhancement.

For some applications, for the purpose of enhancing an anatomicalstructure, the shape and/or orientation of which structure varies duringits motion cycle, some or all of the following steps are performed:

-   -   a. The anatomical structure in a selected image frame is        identified. For some applications, the identification is        automatic (for example, the most significant occlusion along an        imaged vessel is automatically identified). Alternatively, the        identification of the feature is manual (for example, by the        user clicking on the occlusion or in the vicinity of the        occlusion in order to initiate the automated QVA disclosed        hereinabove).    -   b. The same anatomical feature is identified, typically by means        of image processing, in additional image frames which are        typically part of the same image sequence to which the frame in        the preceding step belongs. For some applications, such means of        image processing include pattern matching, and/or non-rigid        object tracking techniques. For some applications, the image        processing includes QVA techniques.    -   c. Image frames are realigned, typically automatically, such        that the orientation of the anatomical feature in at least most        of them is similar.    -   d. The aligned image frames are then displayed, according to        techniques disclosed hereinabove, in the form of a stabilized        image stream or an image stream that is both stabilized and        enhanced.    -   e. The shape of the aforementioned anatomical feature may vary        over the organ's motion cycle. For example, in the area of the        occlusion, an occluded vessel may be straight in some phases and        twisted in others. For some applications, a baseline image frame        is identified, in which the feature is in a shape that is        designated as a baseline shape. The anatomical feature is        identified in image frames in which the feature does not have        the baseline shape, and, in such image frames, the feature is        deformed, such that its shape becomes more similar to the        baseline shape. The image frames in which the feature has been        deformed are displayed in an image stream, together with the        baseline image frame. Typically, this results in an image stream        in which the shape of the feature is more similar along the        image stream, than if the feature had not been deformed in some        of the image frames. The deformation of the feature is typically        performed automatically.

The deformation described in step (e) above typically facilitates thegeneration of an enhanced composite image, or enhanced image stream,which is of higher clarity (with respect to the anatomy of the feature)compared with the pre-deformation enhanced image or movie. For someapplications, the visibility of the feature in an image stream isincreased by deforming the feature as described above, but withoutapplying other image enhancement techniques.

For some applications, the enhancement of images of vessels facilitatesthe demonstration of such vessels not by pure contrast agent (as istypically done without applications of the current invention), butrather with a mixture of contrast agent with a dilutive agent such assaline. Using a lower total quantity of contrast agent typically reducesrisks to the subject's health that may be associated with such an agent.For some applications, mixing of the contrast agent with the dilutiveagent is performed by means of a faucet device to which reservoirs ofthe agents are connected.

For some applications, image enhancement is performed during thepositioning of a tool, during the deployment of the tool, and/or uponthe completion of the deployment of the tool. For example, an enhancedimage or image stream may be used to evaluate whether a tool has beenfully deployed.

For some applications, the edges of the enhanced tool are automaticallyemphasized. Alternatively or additionally, measurements of the enhancedtool are automatically generated and displayed. Such emphasis of edgesand addition of measurements may be useful, for example, to evaluatewhether the tool has been fully deployed.

For some applications, enhancement is generated from fluoro (i.e., lowdose) images as opposed to cine (i.e., high dose) images, despite thetypically-lower quality of such images in comparison to cine images.Alternatively, enhancement is generated from cine images.

For some applications, a sequence of endoluminal cross-sectional imagesgenerated by an imaging catheter along a vessel segment is displayedtogether (such as side-by-side) with the enhanced image of that segmentand/or of a tool positioned (for example, a balloon) or deployed (forexample, a stent) within that segment. For example, the imaging cathetermay be an IVUS catheter, an OCT catheter, a NIRS catheter, and MRIcatheter, or any combination thereof.

For some applications, enhancement is performed continuously and on-linein the form of a tracked and enhanced image stream. For example, suchenhancement may be performed upon a determined number of recent frames,the determined number being set automatically by the system, or setand/or adjusted by the user.

For some applications, enhancement is performed by generatingexponential moving average images. For some applications, enhancement isperformed by averaging sets of two or more image frames that have beenimage tracked, in order to generate a plurality of averaged imageframes. Thus, moving components in the image frames are, at least tosome extent, averaged out, whereas components that appear to bestationary (e.g., the region of the image frames with respect to whichthe frames are tracked) remain. Subsequently, the averaged image framesare typically displayed as an image stream. For some applications, amoving-average image frame is generated, and an image frame (typically,the most recently acquired image frame) is averaged with themoving-average image frame, in order to generate a new moving-averageimage frame. Typically, the moving average image frame is an average (ora weighted average) of all of the previously acquired image frames of agiven sequence. Alternatively, the moving average image frame is anaverage (or a weighted average) of a given number of most-recentlyacquired image frames. This process is repeated in order to generatefurther moving-average image frames. For some applications, the movingaverage image frame and the image frame that is averaged therewith, areassigned different weightings. Typically, successive moving-averageimage frames are displayed as an image stream.

For some applications, the aforementioned tracked andcontinuously-enhanced on-line image stream is displayed side by sidewith the native image stream, or the video-tracked image stream, or thegated image stream, or an image sequence of a typically-recent contrastinjection, or a typically-recent static angiographic image frame, or atypically-recent static angiographic image frame with the markers orradiopaque segments of a tool displayed thereon, or any combinationthereof.

For some applications, a mask is applied to the tracked andcontinuously-enhanced image stream such that the areas more remote fromthe tracked markers or radiopaque segments, which typically have greatermotion, are blurred, hidden, or partially hidden. Typically, an imagestream that is masked in this manner is easier for a user to observe.

Reference is now made to FIG. 24, which shows an enhanced image of aninflated coronary balloon, in accordance with some applications of thepresent invention. As shown, edges have been emphasized with a line anddimensions have been provided, in accordance with some applications ofthe present invention. Typically, the edges are emphasized, and/or thedimensions are provided, automatically.

Reference is now made to FIG. 25, which shows an automatically-enhancedimage frame 87 of a deployed coronary stent that was generated, inaccordance with some applications of the present invention. The enhancedimage was generated from fluoro (i.e., as opposed to cine) images, whichtypically renders such enhancement more difficult to perform. Theenhanced image is shown alongside a native image frame 88 of the imagestream from which the enhanced image was generated. For someapplications, QVA measurements, and/or a QVA diagram are displayed onthe screen, for example in a QVA box 89.

Reference is now made to FIG. 26, which shows a frame of a tracked andenhanced image stream (on the right) displayed side by side with a frameof the native image stream, in accordance with some applications of thepresent invention. An ROI 90 is indicated in the native image stream,within which a stent having markers 92 is located. For someapplications, only the ROI is displayed in the tracked and enhancedimage stream. It may be observed that in the tracked and enhanced imageframe, markers 92 and struts 94 of the stent are more visible than inthe native image frame. The struts are more visible due to the vicinityof the struts to the markers, the image frames having been tracked andenhanced with respect to the markers. For some applications, QVAmeasurements, and/or a QVA diagram are displayed on the screen, forexample in a QVA box 95.

Reference is now made to FIG. 27, which shows a frame 96 of a trackedand enhanced image stream (on the right) displayed side by side with arecent angiographic image frame 97, in accordance with some applicationsof the present invention. Markers 93 of an inflated balloon may beobserved in both of the images. For some applications, QVA measurements,and/or a QVA diagram are displayed on the screen, for example in a QVAbox 98.

For some applications, an image stream is enhanced with respect to atool, such as an inflated balloon, or a deployed stent. An analysissimilar to the QVA analysis, which was described hereinabove withrespect to vessel edges, is performed and displayed for the edges of aboosted tool.

Additional Techniques for Image Improvement

Images of the heart and its vicinity often comprise additional elementsthat are not part of the heart itself and/or its vascular structure.Some of these elements are natural ones, such as the rib cage or spine.Some of these elements are artificial elements that were placed withinthe subject's body in the course of a previously-performed coronarybypass surgery, or that are currently placed on or within the subject'sbody. For example, the elements may include wires (e.g., CABG wires, orguide wires), electrodes, leads, and/or clips (e.g., CABG clips). Suchelements typically appear within a fluoroscopic image as particularlydark (or particularly light in an inverted image).

Such elements, and in particular the latter, artificial ones, mayincrease the burden placed upon the physician observing the images, asthey often divert the physician's visual attention from the heart andthe vascular structure. Such diversion of attention may be caused by theadditional elements moving at a different frequency and/or magnitudefrom the heart and its vasculature. In addition, such diversion ofattention may be caused by the additional elements being of a differentcolor or gray level from the heart and its vasculature.

For some applications, such additional elements are removed, in full orin part, from a stabilized (e.g., an image tracked) image stream. Forexample, such elements may be identified automatically, and the graylevel of such elements may be changed such that they become more similarto the general background of the cardiac image. For some applications,such elements are identified and then removed from the stabilized imagestream by means of a temporal or spatial filter, utilizing the fact thattheir motion may differ in time and/or relative location from the motionof the heart itself.

For some applications, elements are removed from the stabilized imagestream, and the resulting gap is bridged by means of image processing.For example, bridging may be performed by means of gradually changingthe gray level (or color) from its value at one side of the gap to itsvalue at the other side of the gap.

For some applications, such elements automatically become less visiblein the stabilized image stream, compared with their visibility in thenative image stream. Typically this is because the images are nottracked with respect to such elements. Therefore, the relative positionof such elements within the image frame typically changes in successiveimage-tracked image frames. For some applications, as describedhereinabove, the image-tracked image frames are averaged, whichtypically further reduces the visibility of such elements.

For some applications, such elements are removed from the stabilizedimage stream by means of applying a mask, the mask having been derivedfrom a road map that is generated automatically, as describedhereinabove. For example, based upon the road map, a mask is applied tothe image stream such that (a) the visibility of portions of the imagestream that lie within the road map, and within a given distance fromthe road map, is not reduced, but (b) the visibility of other portionsof the image stream is reduced.

In another example, based upon the road map, a mask is applied to theimage stream such that (a) the visibility of portions of the imagestream that lie within the road map have the smallest amount ofreduction (if any), and (b) the visibility of other portions of theimage stream is reduced, such that portions of the image stream furtherfrom the road map tend to be reduced more than portions of the imagestream closer to the road map.

For some applications, a set of masks are generated, each of the maskscorresponding to a respective phase of the cardiac cycle. When the imagestream is displayed, masks are applied to image frames of the imagestream in sequence, such that when an image frame showing blood vesselsduring a given phase of the cardiac cycle is displayed, thecorresponding mask is applied to the image frame. Alternatively, a maskis generated corresponding to a given phase of the cardiac cycle. Theimage stream is gated to the same phase of the cardiac cycle, and themask is applied to the gated image stream.

Example 1 of a Coronary Procedure

Reference is now made to FIG. 28, which is a flow chart of a sequence ofsteps, one or more of which may be performed in a coronary angioplastyprocedure, in accordance with some applications of the presentinvention. For some applications, the steps of the procedure are notperformed in the order in which they are shown in FIG. 28. Typically,the procedure includes one or more of the following steps:

-   -   a. During the diagnosis of the coronary tree by means of        angiography, a road map is automatically generated upon each        angiographic sequence.    -   b. For each road map, measurements are generated automatically        or mostly automatically, typically relatively to some known        reference dimension.    -   c. Lesion and/or artery dimensions, or distance indicators for        such dimensions, are identified automatically or mostly        automatically, typically relatively to some known reference        dimension.    -   d. Tools (e.g., balloons and stents of specific dimensions) are        selected based upon those measurements.    -   e. A road map is presented side-by-side with, and (optionally)        is occasionally overlaid upon, the current fluoroscopic image        stream. The fluoroscopic image stream may be native or        stabilized.    -   f. An ROI is determined automatically or indicated by the user.    -   g. Once a tool has entered the ROI, its radiopaque        segment(s)/markers(s) are automatically identified by the        system. For some applications, the user clicks on the tool or in        the vicinity of the tool, at which point automatic        identification of the segment(s)/marker(s) commences. For some        applications, in response to determining the position of the        radiopaque segment(s)/markers(s), the shape of the road map is        adjusted.    -   h. The fluoroscopic image stream and/or the road map is        automatically zoomed into the ROI.    -   i. Image tracking commences automatically on the radiopaque tool        segment(s)/markers(s). A tracked image stream is generated and        displayed. Motion of the tool over the course of the heart's        motion cycle, relative to the vessel and, specifically, relative        to a designated lesion, is observed and (optionally) highlighted        by graphical means.    -   j. The pre-deployed tool is positioned such that its location is        appropriate, relative to the designated lesion, at a selected        phase of the cardiac cycle.    -   k. Tool deployment is performed such that it is synchronized,        during some or all of the deployment process, to the selected        phase in the cardiac cycle.    -   l. Tool images are enhanced, both during the deployment and upon        its completion, to assess the properness of the deployment. For        some applications, such enhancement is performed and displayed        continuously and on-line in the course of tool positioning,        deployment and post-deployment. For some applications, image        tracking, and/or image enhancement, before, during, and/or after        the deployment of the tool is performed with respect to the        lesion.

Example 2 of a Coronary Procedure

Reference is now made to FIG. 29, which is a flow chart of a sequence ofsteps, one or more of which may be performed in a coronary angioplastyprocedure, in accordance with some applications of the presentinvention. For some applications, the steps of the procedure are notperformed in the order in which they are shown in FIG. 29. Typically,the procedure includes one or more of the following steps:

-   -   a. During the diagnosis of the coronary tree by means of        angiography, an angiographic image frame suitable for a road map        is derived, typically automatically. For some applications, the        sequence leading to such derivation is the one described with        reference to steps 1 through 5 of FIG. 1. The derived        angiographic image frame is displayed, typically without        displaying a road map. Steps a and b of the present flow chart        may be repeated for multiple viewing angles and/or different        sections of the coronary tree.    -   b. For each derived angiographic image frame, measurements are        generated automatically or mostly automatically, typically        relatively to some known reference dimension.    -   c. Lesion and/or artery dimensions, or distance indicators for        such dimensions, are identified automatically or mostly        automatically, typically relatively to some known reference        dimension.    -   d. Tools (e.g., balloons and stents of specific dimensions) are        selected based upon those measurements.    -   e. A suitable angiographic image frame is presented side-by-side        to the fluoroscopic image stream. The fluoroscopic image stream        may be native or stabilized. The frames may be presented        side-by-side in real time, near real time, or in reloop mode.    -   f. An ROI is determined automatically or indicated by the user        in either the angiographic image frame, or, as is typically the        case, in the current fluoroscopic image stream.    -   g. Once a tool has entered the ROI, its radiopaque        segment(s)/markers(s) are automatically identified by the        system. For some applications, the user clicks on the tool or in        the vicinity of the tool, at which point automatic        identification of the segment(s)/marker(s) commences.    -   h. The fluoroscopic image stream, and/or the angiographic image        frame is automatically zoomed into the ROI, according to some        predetermined zoom factor, or according to a zoom factor that is        input by the user.    -   i. Image tracking of the fluoroscopic image stream commences        automatically with respect to the radiopaque tool        segment(s)/markers(s). A tracked image stream is generated and        (optionally) displayed. Motion of the tool over the course of        the heart's motion cycle, relative to the vessel and,        specifically, relative to a designated lesion, may be observed        and (optionally) highlighted by graphical means.    -   j. An image stream that is both tracked and enhanced is        displayed. In accordance with respective applications,        enhancement is performed with respect to a vessel highlighted by        contrast agent, a balloon being inflated, a deployed stent, or        any combination thereof.    -   k. The pre-deployed tool is positioned such that its location is        appropriate, relative to the designated lesion, at a selected        phase of the cardiac cycle.    -   l. Tool deployment is performed such that it is synchronized,        during some or all of the deployment process, to the selected        phase in the cardiac cycle.        Percutaneous Valve Replacement and/or Repair

Although some applications are described herein with respect to thediagnosis and treatment of the coronary arteries in the context ofcoronary angiography and/or angioplasty, the scope of the presentinvention includes applying the apparatus and methods described hereinto other medical procedures. For example, the apparatus and methodsdescribed herein may be applied to percutaneous valvuloplasty, and/orreplacement and/or repair of a valve (also known as percutaneous valveprocedure), such as an aortic valve, a mitral valve, a pulmonary valve,or a tricuspid valve. For some applications, the percutaneous approachis transvascular (such as transfemoral). Alternatively, the percutaneousapproach is via an incision (such as transapical). For someapplications, using the techniques described herein facilitates accuratedeployment of the valve, relative to the surrounding anatomy, evenwithin a beating heart, or a moving vessel.

Reference is now made to FIG. 30, which is a flow chart of a sequence ofsteps, one or more of which may be performed in a percutaneous valveprocedure, in accordance with some applications of the presentinvention. For some applications, the steps of the procedure are notperformed in the order in which they are shown in FIG. 30. The procedureis described herein using percutaneous aortic valve replacement (PAVR)as an example. However, the scope of the present invention includesapplying the procedure described hereinbelow to any percutaneous valveprocedure, applied to any valve, using any suitable equipment, andperformed via any percutaneous access route. Typically, the procedureincludes one or more of the following steps:

-   -   a. The region of the current valve (e.g., the native valve, or a        previously-placed replacement valve) is imaged pre-operatively,        such as by CT, ultrasound, or using a different imaging        modality.    -   b. The pre-operative images are analyzed to determine the        desired location, position and dimensions of the new aortic        valve. For some applications, target lines pertaining to the        desired location and/or angle of the positioned valve are added.        Alternatively or additionally, virtual valves are deployed using        some of the techniques described hereinabove. Optionally, such        pre-operative images are later registered to, and displayed in        conjunction with, the intra-operative image stream. For some        applications, intra-operative images generated by rotational        angiography or CT-like cross-sectional angiography, typically at        the beginning of the procedure, are later registered to, and        displayed in conjunction with, the intra-operative image stream.    -   c. An intra-operative injection of contrast agent under        fluoroscopic imaging into the ascending aorta is detected,        typically automatically, using the techniques described        hereinabove. This step is typically performed on multiple        occasions in the course of the procedure, upon a contrast agent        being administered to the subject.    -   d. Reference is now made to FIG. 31, which shows a road map of        the ascending aorta 100, in accordance with some applications of        the present invention. Typically, the road map is generated        automatically, in accordance with the techniques described        herein. Typically, one or multiple image frames of the contrast        agent are utilized for generating a road map of the ascending        aorta (or a portion thereof such as the lower portion adjacent        to the location of the native valve), typically automatically,        and typically on-line, using techniques described hereinabove.        For some applications, the road map includes a center line 102        which may later be useful for leading the valve into position        and/or placing the valve at a desired orientation relative to        the native anatomy. Alternatively or additionally, the road map        includes target lines pertaining to the desired location and/or        angle of the valve after it will be positioned. Further        alternatively or additionally, the road map includes segments        104 of the coronary arteries, which may later be useful for        ensuring that the new valve is positioned so that it does not        block any of the coronary arteries. For some applications, the        road map also includes calcified portions of the anatomy (such        as calcifications in the existing valve, in the aorta, in        sections of the coronary arteries connecting to the aorta, or in        other portions of the subject's body). Alternatively or        additionally, the road map includes a radiopaque portion (such        as a ring) of a previously-placed replacement valve which may        later be used as a reference for positioning a new replacement        valve.    -   e. Image tracking is applied to the intra-operative image        stream, typically automatically. For example, one or more        observable features are tracked, such as radiopaque segments or        markers of the valve delivery device, of one or more sections of        the valve itself which may be radiopaque by design or become        radiopaque due to the presence of contrast agent within it, or        one or more sections of a previously-placed replacement valve.        For some applications, one of the techniques for image tracking        and stabilization described hereinabove are applied to the PAVR        procedure. Thus, for some applications, a stabilized image        stream is displayed in real time or near real time. For some        applications, the image stream that is displayed is gated to a        selected phase in the cardiac cycle, and (optionally) gap        filling among the gated image frames is applied.    -   f. The road map is registered, typically automatically, and        typically on-line, to the fluoroscopic image stream of the        corresponding anatomy. In accordance with respective        applications, the road map is registered to the fluoroscopic        image stream that has or has not been stabilized (for example,        via image tracking) Typically, based on the registration of the        road map to the fluoroscopic image stream the road map is        overlaid on the fluoroscopic image stream. Further typically,        fiducials are identified within the road map and within the        fluoroscopic image stream, in order to facilitate the        registration of the road map to the fluoroscopic image stream.        For some applications, registration fiducials include the edges        of the ascending aorta, the new valve's delivery mechanism,        radiopaque sections of the new valve, calcified portions (which        may typically be observed under fluoroscopy) of the original        valve, a radiopaque portion (such as a ring) of a        previously-placed replacement valve, and/or a radiopaque portion        of a pigtail catheter.        -   Reference is now made to FIG. 32, which shows a road map of            the ascending aorta 106 overlaid upon a fluoroscopic image            stream of the corresponding anatomy. For some applications,            the observable feature(s) used for the aforementioned image            tracking are not the same as the fiducial(s) used for the            aforementioned registration of the road map to the image            stream. For example, a valve or a valve delivery device 108            may be used for image tracking, while a pigtail catheter,            which is generally stable relative to the aorta, may be used            for the registration (including dynamic registration) of the            road map.        -   Reference is now made to FIG. 33A, which shows an image in            which radiopaque markers 110 of a transapical valve delivery            device have been identified for the purpose of image            tracking The markers are typically identified automatically,            as described hereinabove. The markers are highlighted in the            image. Reference is also made to FIG. 33B, which shows an            image in which a transfemoral pigtail catheter 112 has been            identified for the purpose of registering the image to a            road map. The pigtail catheter is typically identified            automatically, using techniques similar to those described            hereinabove (e.g., using pattern matching). The catheter is            highlighted in the image.        -   For some applications, the aforementioned valve and the            aforementioned pigtail catheter are inserted via similar            routes of access (such as transfemoral). Alternatively, the            valve and the pigtail catheter are inserted via different            routes of access (for example, the valve may be inserted            transapically, while the pigtail catheter is inserted            transfemorally).    -   g. For some applications (for example, if the valve itself is        not sufficiently radiopaque to be clearly visible in the        fluoroscopic image stream), a graphic of a valve is generated,        based on a known geometrical location of the valve relative to        the radiopaque valve delivery device, or to a feature (e.g., a        stent) to which the valve is fixed. Typically, most of the        replacement valve is illustrated graphically. However, for some        applications, only the distal edge of the valve is graphically        illustrated, but the remainder of the valve is imaged.        -   Reference is now made to FIG. 34, which shows a valve 114            that has been graphically illustrated. Typically, the valve            is graphically illustrated based on its known relative            location to radiopaque valve delivery device 108.    -   h. The valve delivery device is positioned, optionally using the        road map, such that the location of the pre-deployed valve (or        of the aforementioned illustrated valve) in the typically        stabilized image stream is appropriate, relative to an        implantation location of the valve. For example, a line marking        the distal edge (or any other known section) of the new valve        may be guided toward a target line in the road map till the two        significantly overlap. Alternatively or additionally, a line        marking the longitudinal orientation of the new valve is guided        toward a longitudinal target line in the road map till the two        significantly overlap. Reference is now made to FIG. 35, which        shows a pre-deployed graphically illustrated valve 118        positioned upon a stabilized image stream of the aorta 120 on        which a road map 116 has been overlaid.    -   i. In the prior art, certain replacement valves are typically        deployed under rapid pacing in order to momentarily neutralize        the aortic blood flow (which is typically very forceful). For        some applications, techniques are provided to account for cases        of “valve shift,” i.e., cases in which once rapid pacing is        stopped and the forceful flow of blood along the aorta resumes,        the implanted valve shifts distally relative to its original        position of deployment. For example, the valve may shift due to        a “sail in the wind” effect of the blood flow on the valve.        Thus, for some applications, the positions of the pre-deployed        valve are determined at different phases in the cardiac cycle,        such as systole and diastole, during the subject's normal heart        beat, and not during rapid pacing. Determination of the valve's        positions is typically facilitated by observing an image stream        that has been stabilized by means of image-tracking the        pre-deployed valve, according to techniques described        hereinabove. For some applications, it is determined that the        pre-deployed valve shifts by a distance D mm along the vessel        over the course of the cardiac cycle. Therefore, the valve is        aimed and deployed at a distance from its designated        implantation location in the ascending aorta that is determined        based upon the observed shift of the valve of D mm. For example,        the valve may be deployed at the distance of D mm from its        designated implantation location. For some applications, the        non-deployed valve shifts by a smaller distance than the        deployed valve, due to blood flow having a greater sail in the        wind effect on the deployed valve than the non-deployed valve.        Therefore, the valve is deployed at a distance that is greater        than D mm from its designated implantation location.        Alternatively, the non-deployed valve shifts by a greater        distance than the deployed valve, for example, due to greater        resistance of the vessel walls on the deployed valve than on the        non-deployed valve. Therefore, the valve is deployed at a        distance that is less than D mm from its designated implantation        location.        -   Typically, the final position of the deployed valve, after            rapid pacing has been stopped and “valve shift” has            occurred, is closer to the designated implantation location            of the valve compared with deployment of the valve when the            shift of the valve is not measured and accounted for,            ceteris paribus. Furthermore, accurate determination of the            valve shift is typically facilitated by the use of a            stabilized image stream for determining the shift of the            pre-deployed valve over the course of the subject's cardiac            cycle. For example, an image stream may be stabilized by            image tracking the image stream with respect to the valve            delivery device, the pigtail catheter, and/or a portion of            the subject's anatomy that is visible even in the absence of            contrast agent (e.g., calcification around the native            valve). The valve shift is determined by observing the shift            of the valve relative to the vessel in which it is to be            deployed, using the image tracked image stream.        -   For some applications, similar techniques to those described            with respect to valve shift are applied to account for            similar shifting of other tools, such as a stent, or a            graft.    -   j. The valve is deployed. Optionally, deployment is        synchronized, in one or more steps, to a selected phase in the        cardiac cycle. For some applications, synchronization is        performed by a synchronizing device that is connected to the        valve delivery device and times its actuation in a gated (e.g.,        stepwise) manner to a selected phase in the cardiac cycle. For        some applications, the synchronization reduces or eliminates the        need for rapid pacing during a deployment of a valve that        otherwise would have required such pacing. For some        applications, deployment of the valve is synchronized to the        same phase with respect to which the stabilized intra-operative        image stream is gated. For some applications, the        synchronization is also applied to a preceding pre-dilatation        step, in which the original valve is dilated, such as by means        of a balloon, in order to overcome typically-rigid calcified        sections and create a space into which to place the new valve.        Reference is now made to FIG. 36, which shows a        graphically-generated image 124 of a valve being deployed within        the ascending aorta. The current outer diameter 126 of the valve        is displayed on the image, in accordance with some applications        of the present invention.        -   For some applications, the original (i.e., native) valve is            not replaced but rather it is repaired. For example, such            repair may include the further coupling, such as via            suturing or clipping, of leaves of the native valve to one            another. For some applications, pertaining to valve repair            (such as mitral valve repair), synchronization is applied to            suturing and/or clipping of the cyclically-moving leaflets            of the valve. Typically, the synchronization of these            procedures facilitates the performance of these procedures            because the leaflets shift rapidly back and forth            (typically, according to the heart beat). Typically, the            synchronization is such that the joining tool is actuated at            the phase of the cardiac cycle during which the leaves are            closest to one another.        -   For some applications, synchronization is applied to the            deployment of a stent-less valve (i.e., a prosthetic valve            typically lacking any rigid supporting structure, such as            the Direct Flow valve), which is deployed by being inflated            at its designated implantation location. Typically,            synchronization is applied to the inflation of sections of            the structure of the new valve.    -   k. At any phase along the process and for any road map,        measurements may be generated, automatically or mostly        automatically, using techniques described hereinabove.        Typically, measurements are performed relative to some known        reference dimension such as the diameter of the valve delivery        device or the distance between radiopaque elements of the valve        itself. For some applications, the measurements include the        current size (such as length and/or outer diameter) of the valve        while it is being expanded in position, the diameter of the        aorta, the space available for deployment of the replacement        valve, the distance between the original valve and the aortic        ostia of the coronary arteries, the distance between the        replacement valve and the aortic ostia of the coronary arteries,        the distance between the lower edge of the replacement valve and        the aortic annular line, the inner diameter of the replacement        valve, the outer diameter of the replacement valve, or any        combination thereof. For some applications, measurements are        displayed in conjunction with the road map, and/or a        fluoroscopic image of the valve. Reference is now made to FIG.        37A which shows, displayed on a fluoroscopic image of a valve        deployed in the ascending aorta, measurements of a current        length 128, and current outer diameters 130 of respective        portions of a valve. Reference is also made to FIG. 37B, which        shows, displayed on a fluoroscopic image of a valve deployed in        the ascending aorta, measurements of (a) a distance 132 of the        valve to the coronary ostium, (b) a distance 134 of the valve to        the annular line, and (c) a current outer diameter 136 of the        valve.    -   l. Tool images are enhanced using some of the techniques        described hereinabove, both during the deployment, and upon its        completion, to assess the properness of the deployment. For some        applications, such enhancement is performed and displayed        continuously and on-line in the course of valve positioning,        deployment and post-deployment.

As used hereinabove, the term “valve delivery device” refers both toinsertion elements that are retrieved subsequent to valve deployment,and to fixation elements (such as a stent-like feature) that remaininside the aorta together with the new valve.

Examples of Additional Medical Procedures

Although many of the applications of the present invention are describedwith reference to the diagnosis and treatment of the coronary arteriesin the context of coronary angiography and/or angioplasty, the scope ofthe present invention includes applying the apparatus and methodsdescribed herein to other medical interventions. The scope of thepresent invention includes applying the techniques described herein toany bodily lumen or cavity on which diagnosis and/or treatment may beperformed, including but not limited to the vascular system, the heart'schambers, the bronchial tract, the gastro-intestinal tract, or anycombination thereof, and using any form of imaging and any applicablemedical tool. For example, the techniques described hereinabove can beapplied to any of the following additional procedures, or to anycombination thereof. (For some applications, the techniques describedhereinabove are applied to the following procedures in combination withtechniques described in WO 08/107905 to Iddan, which is incorporatedherein by reference.)

-   -   Percutaneous placement, replacement or repair of a valve as        disclosed hereinabove. It is noted that the applications        described herein pertaining to the suturing of a valve include        the suturing of a native or a replacement valve to a lumen of        the subject's body, and/or the suturing of leaflets of a valve        to each other.    -   Catheterization of pulmonary arteries, applying the tools and        techniques (e.g., guide wire, balloon, stent, occlusion-opening        tools) previously described in the context of the coronary        arteries. For some applications, such a procedure is performed        in conjunction with stabilized imaging as described hereinabove.        For example, an image stream of the procedure is stabilized by        means of image tracking the observable feature(s) of one or more        tools applied in the course of the procedure, in accordance with        the techniques described hereinabove. For some applications, the        image stream is stabilized with respect to a given phase of the        cardiac cycle. Alternatively or additionally, the procedure is        performed in synchronization with the cardiac cycle, so as to        achieve improved deployment of a balloon or a stent, or better        penetration of an occlusion. Typically, the phase during which a        tool is deployed is the same as the phase at which the        pre-deployed tool has been observed to be properly positioned in        the stabilized image stream.    -   Closure of holes in the septal wall, such as in the treatment of        patent foramen ovale (PFO), ventricular septal defect (VSD) and        atrial septal defect (ASD), within the cyclically-moving heart.        In accordance with techniques described herein, a carrier        carrying a closure tool is led to, and positioned at, a desired        anatomical location (such as the site of the hole in the septum)        while both the carrier and the heart anatomy are viewed in an        image stream that is typically stabilized. For some        applications, the image stream is stabilized with respect to a        given phase of the cardiac cycle. Alternatively or additionally,        the image stream is stabilized by means of image tracking the        observable feature(s) of one or more tools applied in the course        of the procedure, in accordance with the techniques described        hereinabove. Subsequently, the closure tool is deployed at the        desired anatomical location at a given phase of the cardiac        cycle. (Deployment of the tool includes its positioning,        assembly, expansion, and/or release from the carrier.) The phase        during which the tool is deployed is typically the same as the        phase at which the pre-deployed tool has been observed to be        properly positioned in the stabilized image stream. For some        applications, the closure tool is deployed by expanding the        closure tool at the given phase during a single cycle.        Alternatively, the closure tool is deployed by expanding the        closure tool in a stepwise manner, at the selected phase, during        more than one cycle.    -   Placement of a stent graft within the cyclically-moving aorta to        treat abdominal aortic aneurysms. In accordance with techniques        described herein, a carrier carrying a stent graft is led to,        and positioned at, a desired anatomical location (such as the        site of the aneurysm) while both carrier and aortic anatomy are        viewed in an image stream that is typically stabilized. For some        applications, the image stream is stabilized with respect to a        given phase of the cardiac cycle. Alternatively or additionally,        the image stream is stabilized by means of image tracking the        observable feature(s) of one or more tools applied in the course        of the procedure, in accordance with the techniques described        hereinabove. Subsequently, the stent graft is deployed at the        desired anatomical location at a given phase of the cardiac        cycle. (Deployment of the stent graft includes its assembly,        expansion and/or release from the carrier.) The phase during        which the tool is deployed is typically the same as the phase at        which the pre-deployed tool has been observed to be properly        positioned in the stabilized image stream. For some        applications, the graft is deployed at the desired anatomical        location at a given phase of the cardiac cycle (such as when the        corresponding section of the target vessel is at its peak        dimensions), without observing stabilized images. For some        applications, the stent is a self-expansible stent.    -   Trans-catheter placement of a bypass graft to a        cyclically-moving vessel. In accordance with techniques        described herein, a catheter carrying a bypass graft (or any        other form of a bypass) is led to, and positioned at, a desired        anatomical location (such as proximally to the site of a total        occlusion) while both carrier and occlusion are viewed in an        image stream that is typically stabilized with respect to a        given phase of the cardiac cycle. Alternatively or additionally,        the image stream is stabilized by means of image tracking the        observable feature(s) of one or more tools applied in the course        of the procedure, in accordance with the techniques described        hereinabove. Subsequently, the bypass graft is deployed at the        desired anatomical location at a given phase of the cardiac        cycle, the deployment typically including departure from the        native vessel proximally to the site of the occlusion and        re-entry to the native vessel distally to the site of the        occlusion. (Deployment of the graft includes its assembly,        expansion and/or release from the carrier.) The phase during        which the graft is deployed is typically the same as the phase        at which the pre-deployed graft has been observed to be properly        positioned in the stabilized image stream. For some        applications, the graft is deployed at the desired anatomical        location at a given phase of the cardiac cycle (such as when the        corresponding section of the target vessel is at its peak        dimensions), without observing stabilized images.    -   Localized energy application to a tissue, such as within the        heart (e.g., cardiac ablation performed by means of radio        frequency ablation, cryoablation, laser, electrocautery, or        ultrasound, to treat cardiac arrhythmia). For some applications,        the present invention facilitates the ablation of endocardial        tissue in a desired pattern, such as a continuous line or a        series of lines, for example, to apply a Maze procedure to the        tissue. For some applications, movement of the ablation tool is        performed in synchronization with a given phase in the cardiac        cycle. Alternatively or additionally, delivery of energy is        performed in synchronization with a given phase in the cardiac        cycle. For some applications, the endocardial tissue is observed        via an image stream that is stabilized with respect to a given        phase of the cardiac cycle, and/or movement and/or actuation of        energy delivery of the tool is synchronized to the given phase,        over the course of a plurality of cardiac cycles. Alternatively        or additionally, the image stream is stabilized by means of        image tracking the observable feature(s) of one or more tools        applied in the course of the procedure, in accordance with the        techniques described hereinabove.    -   Percutaneous myocardial revascularization, such as via creating        holes in the heart muscle in a desired pattern and by means of        an energy delivery or mechanical penetration tool. For some        applications, movement of the tool is performed in        synchronization with a given phase of the cardiac cycle. For        some applications, the tool is actuated (for example, to deliver        energy or drill a hole) in synchronization with a given phase of        the cardiac cycle. For some applications, the endocardial tissue        is observed via an image stream that is stabilized with respect        to a given phase of the subject's cardiac cycle, and/or movement        and/or activation of the tool is synchronized with the given        phase, over the course of a plurality of cardiac cycles.        Alternatively or additionally, the image stream is stabilized by        means of image tracking the observable feature(s) of one or more        tools applied in the course of the procedure, in accordance with        the techniques described hereinabove.    -   Delivering any material or substance, such as, for example, gene        therapy or stem cells, to specific locations in the heart        muscle. For some applications of the present invention, a        substance is injected into the heart muscle in a desired        pattern, such as a series of points spread across a surface        area. For some applications, movement of the tool is performed        in synchronization with a given phase of the cardiac cycle.        Alternatively or additionally, delivery of the substance is        performed in synchronization with the given phase of the cardiac        cycle. For some applications, the endocardial tissue is observed        via an image stream that is stabilized with respect to a given        phase of the cardiac cycle, and/or movement of the tool and/or        delivery of the substance is synchronized with the given phase,        over the course of a plurality of cardiac cycles. Alternatively        or additionally, the image stream is stabilized by means of        image tracking the observable feature(s) of one or more tools        applied in the course of the procedure, in accordance with the        techniques described hereinabove.    -   Repairing tissue in a cyclically-moving portion of a subject's        body, such as in a bypass or a valve or a graft, for example, by        clipping, suturing, gluing, and/or another technique. For some        applications, movement of the repair tool is performed in        synchronization with a selected phase in the cardiac cycle.        Alternatively or additionally, the repair (e.g., the suturing)        is performed in synchronization with a selected phase in the        cardiac cycle. For some applications, the endocardial tissue is        observed via an image stream that is stabilized with respect to        a given phase of the cardiac cycle, and/or movement of the tool        and/or the repair (e.g., the suturing) is synchronized to the        given phase, over the course of a plurality of cardiac cycles.        Alternatively or additionally, the image stream is stabilized by        means of image tracking the observable feature(s) of one or more        tools applied in the course of the procedure, in accordance with        the techniques described hereinabove.    -   Trans Thoracic Needle Aspiration (TTNA), such as when a        cyclically-moving lesion within the lungs needs to be biopsied.        Typically, the techniques described herein facilitate the        prevention of penetration of life-critical organs, during such a        procedure. For some applications of the present invention, an        aspiration needle is led to, and positioned at, a desired        anatomical location in the thorax (such as a lung lesion) while        both the tool and thoracic anatomy are viewed in an image stream        (such as CT images) that is typically stabilized with respect to        a given phase of the respiratory and/or cardiac cycle.        Alternatively or additionally, the image stream is stabilized by        means of image tracking the observable feature(s) of one or more        tools applied in the course of the procedure, in accordance with        the techniques described hereinabove. Subsequently, aspiration        is performed at the desired anatomical location in        synchronization with a given phase of the cardiac and/or        respiratory cycle, which is typically the phase, with respect to        which the image stream was stabilized.    -   Trans Bronchial Needle Aspiration (TBNA), such as when a        cyclically-moving lesion within the lungs needs to be biopsied.        Typically, the techniques described herein facilitate the        prevention of penetration of life-critical organs, during such a        procedure.    -   Neural stimulation in the brain, its activation being        synchronized with an EEG signal.    -   Attaching or placing a tool at a desired location, on or within        a cyclically-moving organ.    -   Moving or directing a tool to a desired location, on or within a        cyclically-moving organ.

It is noted that although section headers are used in various portionsof the present patent application, the techniques described with respectto one of the sections are typically applicable in combination withtechniques described in others of the sections. The use of headers issimply intended to help the reader.

It will be appreciated by persons skilled in the art that the presentinvention is not limited to what has been particularly shown anddescribed hereinabove. Rather, the scope of the present inventionincludes both combinations and subcombinations of the various featuresdescribed hereinabove, as well as variations and modifications thereofthat are not in the prior art, which would occur to persons skilled inthe art upon reading the foregoing description.

1. A method, comprising: inserting a tool into a blood vessel; while thetool is within the blood vessel, acquiring an extraluminal image of theblood vessel; in the extraluminal image of the blood vessel,automatically detecting a location of a portion of the tool with respectto the blood vessel; in response to detecting the location of theportion of the tool, automatically designating a target portion of theblood vessel that is in a vicinity of the portion of the tool; and usingthe extraluminal image, performing quantitative vessel analysis on thetarget portion of the blood vessel.
 2. The method according to claim 1,wherein performing quantitative vessel analysis on the target portioncomprises automatically performing quantitative vessel analysis on thetarget portion.
 3. The method according to claim 1, wherein performingquantitative vessel analysis on the target portion comprises performingquantitative vessel analysis on the target portion in real time.
 4. Themethod according to claim 1, wherein performing quantitative vesselanalysis on the target portion comprises performing quantitative vesselanalysis on the target portion in near real time.
 5. The methodaccording to claim 1, wherein performing quantitative vessel analysis onthe target portion comprises determining a level of occlusion of theblood vessel within the target portion.
 6. The method according to claim1, wherein performing quantitative vessel analysis on the target portioncomprises determining a minimum diameter of the blood vessel within thetarget portion.
 7. The method according to claim 1, wherein the toolincludes a balloon, and wherein inserting the tool comprises insertingthe balloon.
 8. The method according to claim 1, wherein the toolincludes a replacement valve, and wherein inserting the tool comprisesinserting the replacement valve.
 9. The method according to claim 1,wherein the tool includes a stent, and wherein inserting the toolcomprises inserting the stent.
 10. The method according to claim 1,wherein the tool includes a graft, and wherein inserting the toolcomprises inserting the graft.
 11. Apparatus, comprising: a toolconfigured to be placed inside a blood vessel of a subject; anextraluminal image-acquisition device configured to acquire an image ofthe blood vessel, while the tool is inside the blood vessel; a display;and at least one processor, comprising: image-receiving functionalityconfigured to receive the image into the processor; tool-detectionfunctionality configured to automatically detect a location of a portionof the tool, with respect to the blood vessel, in the image;target-designation functionality configured, in response to detectingthe location of the portion of the tool, to automatically designate atarget portion of the blood vessel that is in a vicinity of the portionof the tool; quantitative-vessel-analysis functionality configured toperform quantitative vessel analysis on the target portion of the bloodvessel, using the image; and display-driving functionality configured todrive the display to display an output in response to the quantitativevessel analysis.
 12. The apparatus according to claim 11, wherein thequantitative-vessel-analysis functionality is configured toautomatically perform the quantitative vessel analysis on the targetportion.
 13. The apparatus according to claim 11, wherein thequantitative-vessel-analysis functionality is configured to perform thequantitative vessel analysis on the target portion in real time.
 14. Theapparatus according to claim 11, wherein thequantitative-vessel-analysis functionality is configured to perform thequantitative vessel analysis on the target portion in near real time.15. The apparatus according to claim 11, wherein thequantitative-vessel-analysis functionality is configured to determine alevel of occlusion of the blood vessel within the target portion. 16.The apparatus according to claim 11, wherein thequantitative-vessel-analysis functionality is configured to determine aminimum diameter of the blood vessel within the target portion.
 17. Theapparatus according to claim 11, wherein the tool comprises a balloon.18. The apparatus according to claim 11, wherein the tool comprises areplacement valve.
 19. The apparatus according to claim 11, wherein thetool comprises a stent.
 20. The apparatus according to claim 11, whereinthe tool comprises a graft.